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A History of the American College of Surgeons BY LOYAL DAVIS

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American College of Surgeons

Fellowship of Surgeons

A History of the American College of Surgeons

BY LOYAL DAVIS, M.D., F.A.C.S.

American College of Surgeons AMERICAN COLLEGE OF SURGEONS 55 East Erie Street, Chicago, Illinois 60611-2797 ©1960, by Charles C. Thomas • Publisher ©1973, by American College of Surgeons. ©1981, by American College of Surgeons. ©1984, by American College of Surgeons. ©1988, by American College of Surgeons. ©1993, by American College of Surgeons. All rights reserved. Library of Congress Catalog Number: 59-15598 Printed in the United States of America FOREWORD

The most conscientious historian must deal with legends, and legends grow rapidly. Even the passage of a day begins to turn facts into fanciful and entertaining stories. Interestingly told, these tales combine truth and ridiculousness in such delightful and charming proportions that they are bound to last for a long time. The story of the American College of Surgeons is that of the development and progress of surgery in America. No other medical organization, voluntarily entered into by its Fellows, has exerted such a profound influence upon the discipline and art of surgery in the United States. This book is concerned with the many men, each with his in- cisive personality, who were dedicated to the purpose of elevating the level of the surgical treatment of patients by raising the standards of hospital facilities and continuing the education of the surgeon. It is a chronological and progressive record of the accomplishments and failures of these men, brought together and stimulated by a man with imagination—a dreamer, an enthusiast, a driver—whose mark upon American surgery has been made by the organization which he conceived. The considerable research which provided the material upon which this book is based was performed by Miss Eleanor K. Grimm, who has devoted her life to Franklin H. Martin and the American College of Surgeons. The enormous amount of factual data assembled and indexed by Eleanor Grimm was obtained from published articles and stenographic reports of the meetings of the Board of Regents and various committees. An attempt has been made to confine and contain all of these interesting and detailed facts within this book and to relate them to the individuals concerned and to current events in the world. vi Fellowship of Surgeons Only a few of the original important evidences of the steps by which the American College of Surgeons became a strong influence in the world of surgery have been placed for ready reference in appendices. There are far too many men and women who have devoted themselves to the American College of Surgeons for years, and who have provided invaluable opinions, guidance and help to me, to list here. Their contributions to this book are in many instances hidden but nonetheless they are inestimable in the combined effort which has produced a story about surgery for the entertainment and information of those who read it. LOYAL DAVIS Chicago FELLOWSHIP OF SURGEONS And so they gave their bodies to the Com- monwealth, and earned each for himself praise that will never die. And with it the most glorious of sepulchres, not that in which their mortal bones are laid, but a home in the minds of men where their glory remains fresh to stir to speech or to action as occasion arises.

For the whole world is the sepulchre of famous men, and their story is not graven only on stone from above their native earth, but lives on far away without visible symbol, woven into the stuff of other men's lives. PERICLES' Oration to the Athenian Dead CHAPTER 1

N A WARM, pleasant Sunday evening in September of 1904, four young doctors were seated around the dining table Oof the house at 3210 Lake Park Avenue in Chicago.° They were there at the invitation of Dr. Franklin H. Martin, a dynamic, Indian-erect, red-haired gynecologist who was their teacher and friend. Isabelle and Franklin Martin had built this house on the shore of Lake Michigan after Franklin had finally developed a substantial surgical practice. Now they were able to break the silver cord which kept them in the rented house, their first home, just a few doors from Isabelle's domineering father and mother, the Dr. John H. Hollisters. Isabelle and Franklin were proud of their new home, and almost every Sunday afternoon and evening doctors were among the young guests whom they invited for supper. This Sunday evening, Isabelle was upset. Franklin had told her that he had invited these four young doctors to discuss the founding of a new surgical journal. She had warned him that he was working far beyond his physical strength, that he had enough irons in the fire. As part of the evidence, she listed his growing practice, his experimental work, the Post-Graduate Medical School, of which he was one of the founders, the Poli- clinic Hospital situated on the north side of Chicago to which he made trips across town three times a week. She was as persistent in her opposition to his plan as he was determined to bring it off. He had told her he wouldn't give up the idea until it had been proven that it wouldn't work. He had gone too far in discussing his ideas to stop now. Besides, he had enthusiastic support from his secretary, Margaret Br'wen, and his friends, * See Appendix, Chapter 1:1. 4 Fellowship of Surgeons Dr. John B. Murphy and Thomas E. Donnelley of the famous printing firm. Isabelle did her best during supper to keep the conversation gay and interesting in fields far removed from medicine. Final- ly, Franklin began to tell of the annoyances and difficulties he had experienced in having medical articles published properly. Old-style medical journalism was dry, sterile and commercial, he said. He pointed out that The Journal of the American Medical Association, started in 1883 by his old Professor at the Chicago Medical College, Nathan Smith Davis, was the only medical journal in existence which was not financed and published by a commercial firm. In his enthusiasm, he went so far as to say that doctors were being exploited by the publishers of scientific medical magazines. It was time to organize a surgical journal for practical surgeons, edited by surgeons in practice instead of by litterateurs who were remotely, if at all, connected with the care of patients. The profits from such an undertaking should be used to strengthen the influence and worth of the journal. Isabelle knew that he would not be contradicted or opposed by the four young men who were associated with him in his professional work. William Cubbins and John Hollister were her first cousins; Frederic Besley was their second cousin. Allen Kanavel, the "outsider," had caught Martin's eye when he had been granted the privilege of bringing his occasional patient into the Post-Graduate Hospital for surgery. As they sat and listened, the four young doctors knew that their teacher had thought his plan through to the smallest detail. He said that the journal would be printed by the R. R. Donnelley & Sons Company, the best printing firm in Chicago. He had been assured of this by Ted Donnelley who had become his friend at the Midlothian Country Club to which Isabelle and he belonged. Ted would see to the style, the typography and the quality of paper and promised that it would appear without fail on the first day of each month. John B. Murphy was just as enthusiastic about the idea. There was great need for a fine surgical magazine which would include within it articles in all of the special fields of surgery. Margaret Bowen had mature judgment, was efficient, ambitious and had proven herself Fellowship of Surgeons 5 loyal to Martin's projects. She would be in charge of obtaining advertising and subscriptions, in addition to being his secretary. Finally, there came a pause in the salesman's speech and Kanavel asked how the first issue would be financed, how large a journal it should be and how much a subscription would cost. Martin looked at him and grinned impishly. He knew that Kanavel was the most logical one of the four, the most practical and the one least likely to be affected by his oratory. What was more, Martin knew that he had not quite thought out all of these details but he had enough facts to answer the immediate questions. Isabelle had been listening quietly and was pleased that at least one young man was not completely taken in by this mad scheme. She said that her father had been worried almost to death by an effort, modest in comparison, which he had made to publish a scientific journal without the support of commercial firms. Martin was shrewd enough to realize that the point had come when they should talk without his wife and that he should encourage his guests to volunteer their ideas. He needed help to put his plans into effect and these were the men to do it, particularly Kanavel. Isabelle's opposition dissolved in tears of frustration as they left her behind in the dining room helping her maid clear the table. As a result of the long evening's exchange of thoughts, it was decided that the new surgical journal should have 100 pages, 60 of which would be devoted to scientific articles and 40 to advertising. Donnelley had estimated that the cost of printing such a magazine would be about $600 a month. Martin had stirred each of them with his imagination and enthusiasm, and as they walked to their homes in the clear, bright moonlight, they were unanimous in their praise of his untiring energy, imagination and enthusiasm.

In the latter part of January 1905, at a meeting held in the Union League Club, an editorial staff consisting of E. Wyllys Andrews, Charles S. Bacon, Frederic A. Besley, William R. Cub- bins, Rudolph W. Holmes, John B. Murphy, J. Clarence Web- ster, Cecil von Bachelle and John C. Hollister was appointed. 6 Fellowship of Surgeons Nicholas Senn accepted the position of Chief of the Editorial Staff. In March of 1905, Martin asked that each member of the editorial staff send a list of the names of doctors to whom a subscription letter could be sent and discussed methods of obtaining subscriptions to the new, unproven journal. Twenty- seven hundred dollars had been pledged for advertisements. In May, Franklin and Isabelle Martin had subscribed for 140 of the 240 shares of stock to be issued at a par value of $100. Besley, Cubbins and Kanavel held 20 shares each; Hollister, Mr. Frank Crozier, an attorney, Drs. William E. Schroeder and Charles E. Paddock divided the remaining 40 shares equally. On June 10, 1905, The Surgical Publishing Company of Chi- cago was incorporated by the State of Illinois with the object of "printing, manufacturing, publishing and selling medical books, journals, papers and pamphlets." Events moved rapidly with the election of directors and officers of the newly formed corporation with its office at 103 (later 31) North State Street which was also Franklin Martin's professional office. In addition to economy, having the office of the new surgical journal right where surgeons took care of patients was Martin's idea of being consistent with a scientific magazine edited by practical surgeons. Franklin H. Martin, President; Allen B. Kanavel, Secretary; and Frederic A. Besley, Treasurer, were the officers. To this group, Albert Goldspohn and William R. Cubbins were added to constitute the Board of Directors. Martin became Managing Editor and Kanavel, Asso- ciate Editor. There are few enthusiastic, imaginative men who have the ability to put their ideas into action in a smooth and efficient manner. Most of them need a partner who is often silent, unselfish, modest and without personal ambition to receive public credit for his work. Franklin Martin chose wisely when he made Allen Kanavel the Associate Editor, and it was Kanavel who wrote the first announcement which Surgery, Gynecology & Obstetrics made to the profession: 1

1 This appears in Kanavel's handwriting in a leather bound copy of the first number which was presented to Martin by his young colleagues at Christmas, Fellowship of Surgeons Surgery, Gynecology and Obstetrics is in the hands of those who have had for its development the highest ideals. The editorial staff must be the guarantee of its ethical and scientific standards. The business management is determined to make it a magazine which as a product of illustrated book-making will be chaste, adequate to its purposes, and artistic in appearance. Its commercial transactions will be based on business principles. The journal will contain a wide survey of the surgery, gynecology and obstetrics of the world. 1. Original articles upon practical, experimental, and statistical subjects will be judicially selected from all available sources and will constitute a major portion of the magazine. 2. Comprehensive original abstracts from local and foreign journals will form another important department. 3. New books will be noticed and those deserving consideration will be thoroughly and carefully reviewed. 4. Live subjects will be considered editorially. The editorials will be written by masters who will be selected because of their fitness to speak on the subject under consideration, and such editorials will be, as a rule, signed. 5. Society reports will be a conspicuous feature of the journal. The larger societies at home and abroad will be thoroughly reported each month with adequate stenographic reports of discussions and abstracts of papers when the papers themselves are not published in full. The editorial policy of the journal will be unique, as it con- templates the editing of the magazine by practical men of authority in their respective specialties. This will be accomplished by a systematic division of labor, making it possible for each man to do a small but definite and important part of the whole. This eliminates the figure-heads and stamps with authority the contents of the journal. The journal is financed by a stock company of Chicago physicians, organized for its publication. It has no connection with any other commercial enterprise, but is published solely in the interest of the medical profession. In construction the journal will represent the very highest 1906. It was reproduced in Surg. Gyn. Obst., 100:1, 1955. A. B. Kanavel, Origin of The Journal and The Development of Its Editorial Policy, Surg. Obst., 51:1, 1930. 8 Fellowship of Surgeons class of magazine making. It will be printed upon high-grade enameled paper that it may show illustrations to the best possible advantage. Inserts of lithographic reproductions will be furnished when illustrations of value require them. Care will be observed to cultivate the use of high grade illustrations for all important articles. The normal size and shape of the journal will be similar to that of the American Review of Reviews. The first number of the first volume of the new, ambitious surgical journal was printed by the R. R. Donnelley & Sons Company and made its appearance on July 1, 1905. Even Frank- lin Martin with his vivid imagination and broad perspective did not fully appreciate the scope and power for good to scientific medicine that his journal would make. Franklin H. Martin was born in Wisconsin on July 13, 1857, and can be counted among that group of Wisconsin native-born boys who came to Chicago to study medicine, remained to practice their profession and made significant contributions to the progress of medicine in the Midwest. Nicholas Senn, John B. Murphy, Albert J. Ochsner, Frank Billings and Archibald Church were among his contemporaries and colleagues. Martin's father and mother came from large pioneer families who settled in Wisconsin from Canada and Pennsylvania. His own father never returned from the Civil War, and he and his sister were raised by their stepfather, a carpenter, with their stepbrothers and stepsisters. Farmhand, brickmaker, school- teacher, in turn, Martin worked hard to become self-supporting. His inspiration came from and his confidences were given to a maiden aunt who encouraged him when he talked to her about studying medicine. One blistering summer day Franklin Martin, wiping the perspiration from his brow as he stood in a field of cut oats, saw the country doctor driving along the road in the shade of a row of maple trees. This sight—the beloved old gentleman dressed in white linen as he sat in a buggy with a white canvas top, drawn by a horse protected by a white fly net— was the determining factor which made the young man decide to become a doctor. Keeping the office clean, doing the chores Fellowship of Surgeons 9 in the barn and memorizing word for word a textbook of anatomy might well summarize that first year of exposure to study in his chosen profession. Most medical schools offered two series of lectures given through 20 weeks of each year as the course of study, and if one had the patience to hear them repeated for the third year, he might graduate cum laude. The more energetic and fortunate might have acquired a cadaver by fair means or foul, usually the latter, to do a sketchy and badly supervised dissec- tion. Several hundred strong, the students sat on narrow seats with straight backs in an amphitheater and looked down as the professor placed his stethoscope on the chest of the patient, assumed a grave countenance and announced his findings. They graduated without ever having felt a patient's pulse or listened to the heart sounds; many of them had never attended a woman in labor. Their teachers were owners of the schools which they attended, and faculty incomes were directly dependent upon the number of students enrolled. The students were a rough lot collectively. They were supposed to be high school graduates and to have served a kind of apprenticeship of one year under a physician who, as their preceptor, certified to this fact as well as to their character. They clapped, stamped, jeered and otherwise expressed their approval, or disapproval, at will. However, there was a medical school, the Chicago Medical College, founded by Nathan Smith Davis and his colleagues, which had broken away from the old tradition and had instituted a graded curriculum of study. It was there Franklin Martin enrolled in 1877. The curriculum included descriptive anatomy, physiology, histology, inorganic chemistry, materia medica, dissections, practical training in the use of the microscope and practical work in the chemical laboratory. The descriptions in the catalog were filled with impressive sounding words. The young man's professors practiced the art of medicine almost to the exclusion of scientific facts because there was such an appalling lack of facts. The microscope was just being viewed as an adjunct in the practice of medicine rather than as a curiosity. Bacteriology 10 Fellowship of Surgeons was becoming recognized as a science because of Pasteur's discoveries; Lister had presented his work upon antisepsis in surgery 13 years previously, but acceptance had not come to him in his own country and operations carried out in Chicago under the carbolic acid spray were rarities. Only the intellectuals in the profession had accepted the germ theory of disease and the controversy was acute, as it had been concerning Darwin's theory of evolution. In fact, there was disagreement among the members of the faculty. Professor Davis, the Dean, rejected the germ theory of disease. On the other hand, Professor Andrews, the surgeon, was actively experi- menting with antiseptics, other than the carbolic acid spray, to keep harmful bacteria from surgical wounds. Edmund Andrews was to be the first surgeon in Chicago to use nitrous oxide and oxygen as an anesthetic agent for a patient. The temperature of the body was still judged by observing the moisture or dry- ness of the skin, by the respirations and an almost occult sense which the practitioner possessed. The clinical thermometer was a newfangled "doodad," a sign of affectation. In 1880 when Martin graduated, 90 per cent of all surgical wounds became infected and at least 75 per cent of all abdominal operations performed by those courageous enough to grasp a knife were fatal. The exceptional patients who recovered were those taken care of by men who grasped the principles of antiseptic surgery or had mastered Lister's technique. As an intern, Martin carried a wooden tray which held a limited supply of absorbent cotton, a larger amount of coarse cotton, a long for- ceps, the ever present probe, a bottle containing a 21/4 per cent carbolic solution in thick oil and another with a five per cent watery solution of carbolic acid. Martin vividly described his experiences as he made his rounds of the surgical patients at Mercy Hospital in Chicago:2 There was a murmur of horror from the patients in Ward Five as I appeared. Even now I sometimes waken in the night and hear those wails of protest. Whenever I smell carbolic acid

9 Martin, F. H.: The Joy of Living— An Autobiography. New York, Doubleday, Doran & Co.,/ :200, 1933. Fellowship of Surgeons 11 I visualize a frail, emaciated boy, with large appealing eyes; his leg had been amputated, his thigh was honeycombed with cavities from which stinking pus poured forth, his resistance was at the lowest ebb and his unearthly moans were heart- breaking as I painstakingly treated his wounds twice a day in an effort to heal them. Epidemics of typhoid fever, smallpox and diphtheria were the scourge of Chicago as he began to practice his profession. Bitter controversies were waged over the question of vaccination, while thousands died. Martin inexperienced, with the operating surgeon, the worry over a patient operated upon using Lister's technique. He shared the uncomfortable feeling about not looking at the wound while they obeyed Lister's dictum, "As long as there is no fever or hemorrhage, leave the dressings undisturbed." Probably no one of the junior and senior men who gathered at the end of 10 days to see the dressings removed, the wound exposed under the carbolic acid spray and the stitches removed one by one, had ever seen a wound which had healed by first intention, without suppuration. After opening an office to practice in Central Hall at 22nd Street and Wabash Avenue, living there and boarding out and spending two afternoons each week at the dispensary clinic of his old school, where he treated from 10 to 15 women each afternoon, Franklin Martin gained an occasional patient. He added to his income by tutoring backward medical students at night after his office hours. Three times a week he traveled 10 miles across the city in each direction to attend the neurological service at St. Joseph's Hospital. This interest had been stimulated by a paper by Dr. Weir Mitchell of Philadelphia, which described the treatment of diseases of the nervous system by rest, supplemental feedings, massage and electricity. A paper written upon his experiences with patients in Dr. R. D. Brower's clinic was Martin's first acceptance in a medical journal and he was proud to have it appear in The Chicago Medical Journal & Examiner.3 He attended meetings of the Martin, F. H.: Massage—Its Application. The Chicago Medical Journal & Examiner, 47:26, 1883. 12 Fellowship of Surgeons Chicago Medical Society and still nourished an early ambition to become an ophthalmologist. During his internship, he worked closely with Dr. Edward W. Jenks, a gynecologist who was brought to the Chicago Medical College and Mercy Hospital from Detroit. Martin worked in the dispensary, where he also taught students. Later, he was invited to join the staff of the Policlinic Hospital, where he met and instructed postgraduate students in the technique of pelvic examinations. All of these factors combined to make him decide to confine his practice to gynecological and abdominal surgery. He was one of a group of struggling young doctors in Chicago, all fired by the excitement of the many controversial subjects in medicine which surrounded them. Library facilities were not plentiful. Animal experimentation was carried on secretively and experiences with patients were argued fiercly. Many of these young men had a burning curiosity to seek out answers to questions which puzzled them. The graduating classes of 1880 and 1881 from Rush Medical and Chicago Medical College provided a nucleus of such men. On May 2, 1883, Franklin Martin and Edmund J. Doering, a colleague who practiced in an office a few blocks away, formed The Chicago South-Side Medico-Social Society. Its cumbersome name described its purposes and activities accurately. This society was to promote good fellowship, harmony and union among its members, advance medical science and maintain high professional standards. Members were added to the original group of eight only by unanimous consent. As a result, it remained a small organization for over 60 years.* Soon Frank Billings, Lewis L. Mc- Arthur, Arthur Dean Bevan and James B. Herrick** were added to the roster of the club which met each month for dinner to enjoy each other's company and to hear the presentation of a paper by one of the members. This was a closely bound, enigmatic group who took themselves very seriously. Martin presented the first scientific paper in August of 1883 upon the subject of "Sterility in Women." ° See Appendix, Chapter 1:2. °° See Appendix, Chapter 1:3. Fellowship of Surgeons 13 Presenting their papers gave them training in public speaking; receiving frank criticisms and questions from their colleagues prepared them to meet discussions which they encountered when they appeared before regularly constituted medical societies. Sitting in the front rows on these occasions were fellow members ready to support the speaker if the attack became too vigorous. For many years The Chicago South-Side Medico-Social Society remained a secret society. It was held together by Doering who became the permanent secretary and whose influence kept the group together when they were older, successful and had developed conflicting interests which led to bitterness and recriminations. Invited by the father of one of his fellow charter members of the medico-social club to a meeting of the Chicago Gynecolog- ical Society, Martin met the leaders in the field of obstetrics and gynecology in Chicago. There were discussions pro and con on Lister's techniques and on Marion Sims' use of silver wire sutures and his reported spectacular results in the treatment of vesicovaginal fistulas. These talks stimulated Martin's desire to become what he termed a scientific as well as a practical doctor. They discussed the influence of anatomy, pathology and the importance of bacteriology upon medicine. In rapid succession, Pasteur had written about the streptococcus and staphylococcus; Koch grew the tubercle bacillus; Klebs and Loeffler simultaneously isolated the bacillus which bears their names and causes diphtheria, and chairs of bacteriology were established at Mun- ich and Wiesbaden. Hearing and reading about the use of electricity in the treatment of fibroid tumors of the uterus, and having had some experience in the use of the faradic and galvanic current in Dr. Brower's neurological clinic, Martin devoted his energies to the systematic study of the method proposed by Georges Apostoli. Some safe way had to be found to check the hemorrhage produced by uterine fibroid tumors. Those who dared to open the abdomen were called delibrate murderers. Speakers at the meetings of the American Surgical Association were violently expressing their disbelief in the bacterial origin of infection. 14 Fellowship of Surgeons Gaining the interest of the McIntosh Galvano-Faradic Com- pany of Chicago, Martin devised instruments and machines which he presented, in anticipation of his clinical studies, at the Chicago Medical Society on December 20, 1886. Gradually, the number of private patients increased. At the South Side Dis- pensary, he had opportunities for applying electrical currents for the treatment of the bleeding caused by uterine fibroids. His confidence in his ability to apply the Listerian technique successfully, even in improvised operating rooms in the patients' homes, grew as he surgically removed cystic ovarian tumors. Occasionally, the older gynecologists on the staff granted Mar- tin the privilege of operating upon one of his patients at the Woman's Hospital. He was concerned by what seemed to be great battles between the leaders in the field of gynecology in their arguments pro and con over Listerism. Lawson Tait, the Englishman who was opposed to Listerism, was advocating a new theory of "asepticism." It seemed to Martin that the lurid reports of opinions in the medical literature and the caustic discussions in meetings were not presentations of orderly, scientific facts and theories. Inheriting a love of national politics from his Grandfather Carlin, Franklin Martin attended the conventions of both political parties which were held that hot summer of 1884 in Chi- cago. Dressed in the conventional garb of the best doctors of that day—a silk hat, long black coat and an imposing gold watch chain stretching across his waistcoat—he wanted to see and hear the famed "big four" of the New York delegation— Theodore Roosevelt, Thomas Platt, Elihu Root and Roscoe Conk- ling. Supporting Grover Cleveland against James G. Blaine in the election that fall, Martin managed to combine his first efforts at courtship with his exciting interest in the events of national politics by making up a party of young people and following the election returns as they were posted that night at the Palmer House. This enthusiastic, energetic, untiring Wisconsin farm boy had chosen as his courting target Isabelle Hollister, the small, viva- cious, challenging daughter of one of his medical school pro- Fellowship of Surgeons 15 fessors. The only daughter of the tall, heavy, white-haired and bearded Professor Hollister, there was a strong silver cord which bound her to her father and mother. The Hollisters did not look with much favor upon the young man's formal request to the father that he wished to court their daughter. Franklin Martin was fascinated by Isabelle's opposition to almost every opinion he expressed. He found that he had to marshal all of his thoughts logically and present them forcibly and with clarity to be able to hold his own. She found that he had curiosity and industry and could be introduced to good literature which he had never had the opportunity to explore. He could not be sure how she felt about his wooing because of the many obstacles which her parents put in the way. Finally, he became sure enough of himself to ask Dr. Hollister formally for his daughter's hand. Martin's reception at that interview was so distressing to his pride that he never forgave the pompous, older man. He did, however, gain the concession that if Isabelle would take a trip during which time she would neither see nor correspond with him and upon her return believed her feelings to be unchanged, the parents would not actively oppose their engagement. Martin was disappointed in not receiving even one letter from the object of his affections while she was away. Devoting all of his thoughts and energies to his work and practice, he presented an acceptable thesis for membership in the Chicago Gynecological Society upon "The Normal Position of the Uterus, and Its Relation to the Other Pelvic Organs" on May 29, 1885. 4 He was learning to have an interest in literary research and spent many hours in the medical libraries available to him. In an effort to forget the wounds of his courtship, he concentrated upon his work. His paper, "Electrolysis in Gynecology," was accepted and presented before the American Medical Associa- tion's Section on Obstetrics and Diseases of Women on the afternoon of May 5, 1886, in St. Louis, Missouri. 5 It was re-

4 There seemed to be no rule about the multiple appearance of the same article in those years. This manuscript appeared in one form or another in the American Journal of Obstetrics, 18:973, 1885; the Obstetric Gazette, 8:361, 1885; and in The Chicago Medical Journal & Examiner, 51:23, 1885. 5 Martin, F. H.: Electrolysis in Gynecology with a Report of Three Cases of Fibroid Tumor Successfully Treated by the Method. J.A.M.A., 6:81, 85, 1888. 16 Fellowship of Surgeons ceived well and, with pardonable pride, he submitted to being photographed by the newspapers with the officers of the Asso- ciation. He was worried by the unethical aspects of what he had allowed to be done in the flushed moments of the occasion. However, his fears were allayed when the photographs of the doctors were pushed aside by several portraits of the suspects held in connection with the Haymarket Riot in Chicago, which had occurred on the evening of May 4. His friends in The Chi- cago South-Side Medico-Social Society commented briefly that it was difficult to distinguish the anarchists from the doctors. Carrying out to the letter the bargain she had made with her father, Isabelle finally told Franklin that after a fair and honest effort she had not been able to forget him. She would insist that her father and mother carry out their pledge that her decision now was to be wholly accepted and considered final. The honeymoon after the wedding on May 27, 1886, was spent in their new house which the bridegroom had rented and furnished just a few doors away from her parents' home on Rhodes Avenue. Quite evidently, the 29 year old transplanted Wisconsin boy was willing to make concessions to the emotions of the bride's parents which he was unable to understand completely, coming as he did from ancestors who had families of many children. Martin had been appointed Professor of Gynecology at the Chicago Policlinic. He prepared and gave lectures to students twice a week at this postgraduate college on Chicago Avenue at La Salle Street. He moved his office from the South Side to a building on the corner of State and Monroe Streets, an indication of a growing reputation. Isabelle translated medical articles written in French and insisted that they regularly read to each other from the classics in American and English literature. Thus, she began to teach her willing pupil about the pleasures to be found in books other than those of medicine, a custom which they never stopped during their lifetime together. Like all young doctors, there came a time soon after their marriage when it appeared to him that he was never to have another patient come to his office for advice. Concentrating Fellowship of Surgeons 17 upon his work, writing and presenting papers and taking care of patients in the dispensary did not provide the money with which to support a young wife and his home. This was the first of many times when Isabelle became his gyroscope—balancing his energy, enthusiasm, ambitions, imagination, talent, abilities and his books. Then, the first patient was referred to him from another city. Almost simultaneously, he was appointed attending gynecologist to the Woman's Hospital where private and charity patients were admitted for gynecological and obstetrical treatment only. While he enjoyed his work at the Chicago Policlinic, his suggestions for improving the curriculum and the clinic fell on the deaf ears of the administration. He and a fellow faculty member obtained the support of a strong group to organize a new postgraduate school on the basis that all expenses were to be shared equally and to be paid monthly as bills were submitted. In this provision, Isabelle's tutoring had fallen upon fertile soil. So, in 1889 the Post-Graduate Medical School and Hospital of Chicago opened its doors in a rented four-story building at 31 East Wash- ington Street.6 The school and hospital consisted of a public dispensary and a faculty representing all fields of medicine, composed of several of Martin's old respected teachers and fellow members and friends in The Chicago South-Side Medico- Social Society. It seemed logical that there should be an official outlet for the investigations and teachings of a strong faculty. An agreement was made with Truax & Company, Chicago printers, to publish The North American Practitioner, described as "a highly scientific journal needed in the Middle West," with medical men in practice as its editors. Taking a week away from his professional work, the Martins attended the Republican convention in Chicago in 1888 which nominated Benjamin Harrison who defeated Grover Cleveland, Martin's own party's candidate. They had met President Cleve- land when he had spoken at the ninth International Medical Congress in Washington, the first time it had been held in the United States. The present site of the Marshall Field & Company annex building. 18 Fellowship of Surgeons Soon the Post-Graduate School and Hospital had outgrown its rented quarters, probably due in part to full-page advertisements which appeared in the leading medical and surgical journals. Certainly, no one on the faculty hid his light under a bushel. Martin advocated moving to the South Side in the proximity of his old medical school, Mercy and Wesley Memo- rial Hospitals. Over his opposition, however, the faculty voted to subscribe to a stock issue which would erect a modern building with an elevator and all modern conveniences on Plymouth Court south of Van Buren Street, an area still within what had become to be known as the "Loop." He led the organizational activities with zest and received all of the criticisms without complaint. Martin's surgical work was increasing and he was applying the principles of asepsis as well as he could in his operating room techniques. With Isabelle's help, he recorded faithfully all of his patients' symptoms, physical findings, what was found upon operation, what he had done and the postoperative course. Thus, he was accumulating clinical experiences and facts from which he could draw conclusions. Before the 1890 meeting of the American Medical Association in Nashville, Tennessee, he presented a plea for early removal of the uterus for cancer.? In his rebuttal, he unwittingly antagonized one of his distinguished and older listeners who in discussing his paper had said it was "undigested material which was due to the rashness of youth." It was his old teacher, Nathan Smith Davis, who pointed out to Martin later that his reply was belligerent, ruth- less and indiscreet. Davis went on to say that it would have been more dignified, inasmuch as Martin had been in the right, to have ignored what he considered to have been an insulting discussion of his paper. Isabelle managed to break into his long hours of work by calling for him at his office and taking him on surprise afternoon trips. Often these ended at the Chicago National League Base- ball Club's park on the West Side where they would sit in the

? Martin, F. H.: A Plea For Early Vaginal Hysterectomy for Cancer of the Uterus. /A.M.A., /5:945, 1890; Ibid., /6:877, 1890; Ibid., /7:152, 1891. Fellowship of Surgeons 19 sunny bleachers and relax. Or, she might take him for long walks along the shore of Lake Michigan, which both of them loved, and they would play at choosing a site for a future home which they would build so they would never be away from the sight of the "beautiful pond." He continued to be occupied with the treatment of fibroid tumors of the uterus by the galvanic current and reported upon five patients treated unsuccessfully. It was only the dreaded cancer for which he unqualifiedly recommended removal of the uterus. This benign tumor with its troublesome and repeated bleeding had to be attacked, if possible, by less dangerous methods. The detractors of the use of galvanism insisted that the use of electricity might well destroy the fertile ovum in the preg- nant uterus, interfere with the development of the embryo or even terminate the pregnancy. In every presentation he had made on the subject, he had been careful to insist that treatment should not be given to patients in whom there was a possibility of pregnancy. Needing the backing of scientific data, he conducted experiments at home on hens' eggs which were presumably fertile. The results of his crude experiments convinced him that the galvanic current was fatal to the chick embryo but the faradic current had little effect. It was the first experimental research he had ever conducted, and it aroused his imagination and provided a variety of discussion for Isabelle and him. A belated honeymoon trip down the Mississippi River to New Orleans, the opening of the World's Fair with all of the construction necessary to gain access to the large tract of land set aside for the Exposition buildings, the Democratic party's convention held in Chicago which again nominated Grover Cleve- land—all were kaleidoscoped with his thoughts of a surgical method with a low mortality which would save the frail, wax- faced, anemic women, gradually bleeding to death from their uterine fibroids. Until time-consuming major surgical abdominal procedures could be performed safely, a simple method had to be found. After he had ligated the dilated uterine arteries in several patients for this condition and had successfully terminated their hemorrhages, he found when he came to report his 20 Fellowship of Surgeons experiences that two other surgeons claimed priority for what he believed was an original idea. The Martins delighted in visiting the Exposition grounds, studying the examples of classical architecture which characterized the buildings and seeing their beautiful lines preserved at night by electric bulbs from Thomas Edison's laboratory. They entertained a stream of visitors who were invited to their home but asked to leave on a specified date to make room for their successors. The pace he was keeping eventually exacted its toll and Isabelle suggested a trip to Alaska, which diplomatically included the meeting of the American Medical Association in San Francisco. The latter was his first experience in the politics of a national medical organization. Suddenly, through the activities of his older friend, Joseph Eastman of Indianapolis, he found himself elected the Chairman of the Section on Obstetrics and the Diseases of Women. The following year the American Medical Association met in Baltimore and he first saw the new Johns Hopkins Hospital Medical School and watched the young Professor of Gynecology, Howard Kelly, spectacularly perform a hysterectomy. The accomplishment brought forth prolonged applause from the clinic audience. The following month found Isabelle and Franklin Martin completing careful plans to go abroad to attend the meeting of the British Medical Association and the British Gynecological Society. By carefully planning and husbanding their resources, Isabelle saw to it that they visited France, England and Scot- land. Martin met Sir Joseph Lister and his vocal opponent, Law- son Tait; visited Oxford and the old wards of Lister at Glasgow and Edinburgh. He was stimulated anew to continue trying to contribute to advances in his profession. He also made up his mind to work at the task of responding to a toast or making an extemporaneous speech. That Irishman, John B. Murphy, had put Martin to shame in comparison, when Murphy responded to a toast at a dinner given by the British Gynecological Society to which they had been invited. Murphy spoke easily and with a choice of complimentary words for British surgery. Yet, be had the manner of the master of his Fellowship of Surgeons 21 listeners. Martin had first seen the tall, slender, sandy-haired young Irishman sitting in one of the amphitheaters of the Cook County Hospital, along with the other candidates being examined to become interns. They were seated in a semicircle in front of the members of the attending staff who were to give them the oral examination. In the seats of the amphitheater were fellow students from both Chicago Medical and Rush Medical Colleges there to applaud or stomp for their favorites. Martin had been an interested onlooker, glad that he had already been accepted for his internship and didn't have to submit to such an ordeal. It was the young Irishman, Murphy, who had given the best answers, never wanting for the proper words which he expressed with an assured manner in a rather high- pitched voice. Martin and his fellows had found themselves applauding a graduate of the rival school. Now another occasion had drawn his respect for Murphy's abilities. Martin had been correct when he favored moving the Post- Graduate Medical School and Hospital to the South Side in the vicinity of Mercy, St. Luke's, the Woman's, Michael Reese, the new Wesley Memorial Hospital and the new home of North- western University Medical School which had gathered his old alma mater, the Chicago Medical College, into the fold of the University. He and his colleagues and fellow stockholders built a seven-story brick building at 2400 South Dearborn Street, one of the first fireproof hospital buildings to be erected in Chicago. It was planned for 100 patients, a spacious outpatient dispensary and an amphitheater which would seat 250 students. A note which appeared in The Journal of the American Medical Association gave a glowing description: 8

POST-GRADUATE MEDICAL SCHOOL AND HOSPITAL Chicago, Ill. It has just completed a magnificent building, thoroughly equipped for modern scientific post-graduate instruction; con-

8 This was a statement prepared by the school in answer to a circular addressed to the heads of the various medical schools in the United States, requesting them to state their plan of education, including requirements for admission, the facilities they possessed for teaching and the cost of attendance. The Medical Colleges of the United States, J.A.M.A., 27:628, 1896. 22 Fellowship of Surgeons venient surgical amphitheaters, fine, well-lighted laboratories and clinic rooms, comfortable reading and smoking rooms, auto- matic ventilation, electric lights and elevator. The college is located at 2404 Dearborn Street, in the medical center of Chicago, and with unequaled hospital advantages, an abundance of clinic material, comprehensive and advanced curriculum; large working faculty and a continuous course throughout the year. Students may matriculate with equal advantage at any time and receive a post-graduate course that is unsurpassed. For particulars address Franklin H. Martin, M.D., Secretary. This was a proprietary medical school and hospital designed to help educate the doctor graduated in medicine and in practice, who was to learn by seeing things done and receiving lectures from the faculty of experienced men. Though his father- in-law remained one of the stalwarts of Northwestern Univer- sity Medical School, and it was just across the street, Franklin Martin did not become a member of its faculty to aid in the teaching of undergraduate students. Even then, as today, there existed a line between undergraduate and postgraduate medical schools. Certainly, the proprietary nature of the Post- Graduate Medical School and Hospital flaunted completely the principles which prompted Nathan Smith Davis, Hollister and their colleagues to break away from Rush, a proprietary school, and found the Chicago Medical College. Martin was busy, but not too busy however, to enroll in a systematic course in the technique of the new and important science of bacteriology. He was delighted when Isabelle joined him as a student in the course. Bacteriology had not been included in the curriculum when he was a student in medical school, and he knew he must learn all he could about bacteria to apply practically and efficiently the principles of asepsis in the operating room techniques at the Post-Graduate. A thoroughly equipped experimental laboratory was added to the attractive features of the Post-Graduate School in a one-story building constructed a block from the hospital. There students could learn to perform operations upon animals under anes- Fellowship of Surgeons 23 thesia, and the faculty members could begin experimental investigations, if they were so inclined. The objections of the Society for Prevention of Cruelty to Animals were overcome when Martin initiated an invitation for them to come and witness all of the procedures which were carried out upon animals. Grandfather Carlin must have instilled in his grandson a deep interest in the conventions of party politics; Martin was proud of his unbroken attendance at one or the other whenever it was held in Chicago. He had only partially succeeded in interesting his dyed-in-the-wool Republican mate but lured her into going out south to the Coliseum on 63rd Street where the Democratic convention was being held in August 1896. At their convention in St. Louis, the Republicans had already nominated William McKinley of Ohio, but the Democrats had no outstanding or favorite candidate. Isabelle accompanied her husband as a dutiful wife but after two hours of dreary speeches insisted that they leave. As they rose to leave, an ex-Congressman, a delegate from Nebraska, was recognized and began to speak in a commanding, soothing and magnetic voice. This famous Cross of Gold speech won William Jennings Bryan the nomination for the Presidency and brought the admission from Isabelle that, if given the opportunity, she would think carefully before voting against him. Isabelle was continuing Franklin's education by insisting upon their regular attendance at the Chicago Symphony Orchestra concerts, begun under the reign of Theodore Thomas and continued religiously after his succession by Frederick Stock. Reading aloud had continued so that she felt proud of her efforts to open new horizons in literature for the Wisconsin farm boy, who was so receptive and eager to learn. Spurred by a mind which was not purely scientific but needed to search for the application of scientific facts to the problems which caused the patient to suffer, Martin examined his patients carefully and gave their complaints careful thought. Touched by the appearance of a young boy of 13, who came to him 24 Fellowship of Surgeons dressed in girl's clothes to conceal a congenital exstrophy of the urinary bladder, Martin thought that if the ureters could be transplanted into the intestine or the lower bowel, a more nearly normal function could be established. The idea was not a new one. Considerable experimental work had been initiated, and many clinical reports had been presented by surgeons who had accidentally injured or severed the ureters during the course of abdominal operations. In fact, he had marveled at the speed and accuracy with which Howard Kelly had passed catheters which would enable him to identify the ureters easily and avoid damaging them. However, Karl Maydl's research efforts to transplant the ureters had not proven to be sufficiently encouraging for surgeons to carry out the operation upon their patients. With the help of William R. Cubbins, Isabelle's younger cousin, Martin began his experiments. Cubbins, who was just beginning his internship, was fascinated by the word "research," and his enthusiasm was encouraged by the older man. This trait proved to be a valuable asset because their first 12 experimental animals died just as Christian Fenger, the Dane who was stimulating such an interest in surgical pathology, had predicted. The whispering conventionalists ridiculed Martin's efforts to perform experiments on dogs, the results of which could then be transferred to the human patient, always adding the trite and often repeated statement that the results couldn't be considered to be directly applicable. The operation on the thirteenth dog, Bruce, was a success and confirmed Martin's growing belief that 13, the number of his natal day, was always to bring him luck.

The twentieth century had been ushered in by a score of happenings. William Jennings Bryan had been defeated by William McKinley for the Presidency. Like all good Democrats, Franklin Martin resigned himself to wait for another chance. Prophylactic vaccination against typhoid fever had been undertaken and the killer of the largest number of soldiers in the Spanish-American War appeared to be shackled. Roentgen's Fellowship of Surgeons 25 discovery of x-rays at the end of the nineteenth century was being put to practical use in the care of patients, but their danger to the patient and the physician was to be realized 25 years later as skin cancers developed on the hands and face of the users. Carrie Nation, the Kansas anti-saloon agitator, was furnishing lurid copy and photographs for the newspapers as she hacked bars, broke windows, mirrors and bottles with her hatchet and defied the owners and patrons to "harm a hair of her head." Admiral Dewey had destroyed the Spanish Pacific fleet and was paraded through the streets of Washington as a great hero. Dr. Walter Reed led a campaign to study and wipe out yellow fever. At the Pan-American Exposition held in Buffalo, Leon Czolgosz, an anarchist, shot President McKinley, and the rough- rider, Theodore Roosevelt, succeeded to the Presidency. Mar- coni signalled the letter "S" across the Atlantic ocean from Eng- land to Newfoundland. Since a successful automobile trip had been made across the United States from San Francisco to New York by Dr. H. Nelson Jackson and Sewall K. Crocker, it appeared that perhaps a man by the name of Henry Ford might eventually justify his optimistic prophecy about the uses of the automobile when he organized a company to manufacture them. Invited to become a charter member of the newly organized Midlothian Country Club located south of Chicago, Franklin and Isabelle Martin promptly accepted. The roster contained the names of important Chicago citizens in industry. Higgin- botham, Thorne, Montgomery Ward, Shedd, Swift and Don- nelley were families with whom they formed a lasting friendship. Isabelle looked upon the club as a place where she might persuade Franklin to relax over the week-ends and learn to play golf. She had become increasingly alarmed over the pace he set and maintained for 16 hours each day. After more than two years of experimental work and following the successful operation upon Bruce wherein the ureters were transplanted into the bowel, Christian Fenger had come to Martin's laboratory to see the experimental animals for him- 26 Fellowship of Surgeons self. He became just as enthusiastic a supporter of the work as he had so eloquently opposed the idea as being impossible. Martin had extended the original indication which had prompted him to undertake the experiments. In a paper read before the Philadelphia Obstetrical Society9 on April 5, 1900, he proposed to "remove the bladder, preliminary to or coincidental with hysterectomy for cancer, in order to extend the legitimate possibilities of surgery for malignant disease of the pelvis. . . ." Martin had become impatient with the editors of the journals to which he had submitted his papers, particularly those devoted to gynecology and obstetrics which were published and owned by commercial printing companies. He had had firsthand experience with publishing The North American Practitioner which had become defunct. Thomas E. Donnelley, a fellow club member and a favorite partner at golf, was a son of the famous R. R. Donnelley and an important figure in the affairs of the rapidly growing printing company. Martin asked many questions and proposed convincingly that there was a golden opportunity to publish the finest possible surgical journal which would be successful. It should have editors who were practicing their profession and not full-time laymen or "hack" physicians. The quality of the paper should be the finest so that illustrations would reproduce with clear definition of what the author wished to show. There should be no skimping on the number of illustrations used because the story told by a drawing or picture often saved the use of hundreds of words. The typography should be up-to-date and the copy expertly proofread. Above all, the magazine should appear on the first of each month with-

9 Martin, F. H.: Removal of the Bladder as Preliminary to or Co-incidental With Hysterectomy for Cancer in Order to Extend the Possibilities of Surgery for Malignant Disease of the Pelvis. Am. Gynaec. & Obst. I., 16:395, 1900; Mar- tin: Presentation of Specimens and Post-Mortem Findings of Experimental Im- plantations of Ureters in the Bowels. Am. Gynaec. & Obst. J., 14:307, 1899 (Pre- sented at meeting of Chicago Gynecological Society, January 18, 1899, under title of "Experimental Implantation of Ureters in the Bowels"); Martin: Implan- tation of Ureters in the Rectum: A Method Having for its Object the Making of Subsequent Infection of the Ureters and Kidneys Impossible. J.A.M.A., 32:159, 1899; Martin: Further Report on the Implantation of the Ureters in the Rectum, With Exhibition of Specimens. Am. Gynaec. & Obst. J., 14:636, 1899 (Presented at meeting of Chicago Gynecological Society, March 17, 1899). Fellowship of Surgeons 27 out fail. Such a surgical periodical would have ari appeal to the reader and provide an opportunity to stimulate the doctors in small communities to continue their medical education.

The four young doctors whom he had invited that Sunday afternoon had been helped through their medical school years by Franklin and Isabelle Martin. He had given them tasks to perform in their off hours for which they were paid; she had provided a square meal on many occasions. All were graduates of Northwestern University Medical School between 1894 and 1900. William R. Cubbins, a native of Memphis, Tennessee, was Isabelle Martin's first cousin. He had attended Centre College in Danville, Kentucky. Frederic A. Besley, born in Wau- kegan, Illinois, was their second cousin. John C. Hollister from Grand Rapids, Michigan, was a graduate of the Boston Latin School and Yale University before becoming a classmate of Cubbins in medical school. The "outsider" was Allen B. Kanavel, a homely-faced boy from Sedgwick, Kansas, a minister's son, who had worked his way through Northwestern University and its medical school. Quiet and a good listener, he had been stimulated by Franklin Martin to examine his patients carefully and learn from their symptoms. He had served his internship at the Cook County Hospital and had seen thousands of hands mutilated by injury and crippled by infection of trivial lesions which spread into tendon sheaths and fascial spaces. Kanavel, who was alert, imaginative and industrious, was soon taken on as Martin's assistant in surgical cases. Martin helped him obtain the anatomical specimens which he could inject to work out the surgical anatomy of the fascial spaces and tendon sheaths of the hand, Isabelle had always listened with some jealousy and resentment as Franklin extolled the virtues of Kanavel in comparison with the other young men who came to their home. Isabelle Martin's concern about her husband's plans to start a new surgical journal was not based entirely on her fear that an added responsibility might tip the balance and endanger his physical being. She had the experiences of her father in mind and had heard of the many failures of medical periodical pub- 28 Fellowship of Surgeons lications. Until June of 1884, a total of 509 medical journals had been started and flourished for varying short periods of time in the United States with only 136 surviving. These were all reflections of the large number of proprietary medical schools, cults and quack medical practices which existed, each wishing to champion its cause by a controlled publicity organ. Isabelle knew how difficult it was to finance such ventures and to establish any kind of a satisfactory arrangement between editors and printers. The journal of the Post-Graduate Medical School began aus- piciously in 1889 as the North American Practitioner. Edited for a time by her father, it was published by three different printers and finally disappeared in a merger with the Medical Standard in 1899. Dr. N. S. Davis, her father's close friend and colleague, was particularly fond of starting new journals and serving on their editorial staffs. There had been The Chicago Medical Examiner, then The Chicago Medical Journal. To survive, the finances and subscription lists of these publications were consolidated into The Chicago Medical Journal & Ex- aminer. The latter ceased publication in 1889 after Dr. Davis had worked hard to establish an official organ for the American Medical Association, which became a competitor. Isabelle had been over all of these discouraging facts with Franklin many times before and, finally, in complete frustration had realized that nothing would influence him to give up his plans. He had even been uncomplimentary about the ability of her own father to organize and manage a medical journal properly, saying that he was too rigid and unimaginative. The first article in the first number of the first volume of Surgery, Gynecology & Obstetrics was written by the Chief of the Editorial Staff, Dr. Nicholas Senn, under the title "Iodine in Surgery, With Special Reference to Its Use as an Antiseptic." The issue contained 112 pages, 30 of which were devoted to advertising material. Subscriptions numbered 600 at the price of five dollars per year. Margaret Bowen, Martin's secretary, had conducted the campaign for advertisements and subscriptions and had been so successful as to get the first cash subscription Fellowship of Surgeons 29 from Brooks Wells, the editor of a competitor, The American Journal of Obstetrics. In a signed editorial in the first issue, Franklin Martin said that the editors "realize that there is no call for another ordinary surgical journal, and that if they do not succeed in making this journal far beyond the ordinary, there is no reason for its existence." Every effort was to be made to foster the scholarly and scientific aspirations of the surgical profession and it was to be truly an international journal. Adequate illustrations and a conservative literary style were to be combined with the highest possible art in printing and publishing. No personal prejudices or commercial considerations were to influence its editorial policy. There were many moments in the beginning when the life of the newborn magazine hung in the balance. Not enough manu- scripts had been submitted to fill the third number. The Asso- ciate Editor dug deep and, with many misgivings as to the propriety of the action, finally included his own manuscript.' 0 The Transactions of the American Gynecological Society, the Ameri- can Surgical Association, The Chicago Gynecological Society and even the Illinois State Medical Society were reported in detail. By December of 1906, the rolls showed over 2,800 paying subscribers and less than 100 had discontinued their subscriptions. The early average of 96 pages had increased to 140. Over half of the scientific articles pertaining to surgery, gynecology and obstetrics which were published during that past year had appeared in the new journal. There had been a financial deficit of $3,131.68 incurred after taxes had been paid, in publishing the first 12 numbers. There- fore, it was thought wise to increase the capital stock from twenty-five to fifty thousand dollars. This would provide ample support and insure the stability and permanence of the journal considering the planned running expenses and a continuance of normal growth. To gain the interest of European surgeons in the scientific io Kanavel, A. B.: An Anatomical, Experimental, and Clinical Study of Acute Phlegmons of the Hand. Surg. Gyn. Obst., 1:221, 1905. 30 Fellowship of Surgeons surgical work of America, ad hoc associate editorial boards were appointed in the outstanding medical schools and hospitals of the United States and Canada and asked to be responsible for a single number of the journal. Articles were to be contributed by the faculty, or staff, and the number named after the institution. This plan began with the January 1906 issue which came from the Cook County Hospital in Chicago. The next year a similar series from foreign countries was inaugurated. By the end of the third year, the journal had gained so many friends abroad that the publication of an edition for the British Empire was begun. This was aided by a distinguished group of English surgeons which included A. W. Mayo-Robson, B. G. A. Moyni- han, Harold J. Stiles, John Bland-Sutton, John Stephen McArdle and James Rutherford Morison. Nicholas Senn had been untiring in his activity to aid the new surgical journal, and his international reputation had created an immediate and broad interest in the new venture. Senn died in January of 1908, and John B. Murphy succeeded the surgeon whom he had insisted that Martin attempt to interest in becoming the Chief of the Editorial Staff. Martin had done this against his own wishes. He had been encouraged and supported in his early conversations with Murphy about his plans and had desired him as the editorial chief. Murphy already had gained distinction abroad, they were of the same age, they understood the aims and ideals to be accomplished. All this Martin had told him, but Murphy pointed out that the new journal needed acceptance and recognition at home as well as abroad. The use of his name as Chief of the Editorial Staff might well be a handicap which would ruin its chances at home. In the end, Murphy's judgment had prevailed, but now the journal was well established and growing rapidly. There was no need to pussyfoot any longer. Thus began the closer association of the two Wisconsin farmer boys, who had become friends with growing respect for each other's abilities, yet with a clear recognition of their individual characteristic weaknesses and strengths. CHAPTER 2

HE YEARS between Franklin Martin's graduation from medical school and 1910 covered a significant transitional periodT in the development of surgery in the United States. They had brought a change from "laudable pus" to the conception of aseptic surgery. The operating room fog produced by the carbolic spray had been dissipated by antiseptic methods which employed wound washing with a claret-colored solution of tincture of iodine.' Rapid, spectacular operating technique ne- cessitated by crudely administered anesthetics, or no anesthesia at all, gave way to more deliberate and refined methods. Facts had been accumulating swiftly which did not often agree with the procedures in vogue based on tradition handed down from the foreign literature and teachers of medicine. These scantily educated, imaginative, independent pioneers in medicine began to think for themselves and they were maturing as surgeons. In those years of inquiring minds, the leaders were not yet so sure of themselves that they had become provincial. The struggle to organize and raise the standards of undergraduate medical schools was progressing slowly against the entrenched proprietary schools. The use of lectures and clinical and operating room demonstrations was a much easier and more successful educational method to teach graduates in med- 1 The program of the American Surgical Association meeting in Washington, D. C., September 18-20, 1888, contained a paper by Nicholas Senn on the relation of microorganisms to injuries and surgical diseases, which was discussed at length by Mr. Arthur Durham of London, a contemporary of Lister. W. W. Keen spoke about three successful cases of cerebral surgery. John Ashhurst, Jr., made a contribution to the study of excisions of the larger joints, and the presidential address was given by D. Hayes Agnew on the relation of social life to surgical disease. Donald MacLean who had been the Professor of Surgery at the University of Michigan from 1873 to 1887, showed the visible effects of an acute nephritic condition which had resulted from inhalation of carbolic acid vapor. 32 Fellowship of Surgeons icine how to apply the most recent scientific facts for the good of the patient. Methods and technique could be imitated and those eager to learn about surgery could be taught what not to do. The resultant good to the patient could be obtained faster than by waiting for the slow, laborious development of proper curricula and teaching disciplines in medical schools. These pathfinders were watched and criticized for going too fast; it was said to be dangerous to apply results obtained in the laboratory to man. These "progressives," it was claimed, were interested only in tooting their own horns to further their individual ambitions in their profession. Similar explorations for facts in other fields of endeavor were taking place simultaneously. The Wright brothers made a short but successful flight in a heavier-than-air mechanically pro- pelled airplane on December 17, 1903. Robert E. Peary reached the North Pole on April 6, 1909, on his sixth attempt. On July 25 of that same year, Louis Bleriot flew across the English Chan- nel, a distance of 31 miles in 37 minutes. Glenn Curtiss won $10,000 for the first continuous flight from Albany to New York City on May 29, 1910. The new surgical journal, launched so enthusiastically, found itself in the midst of a serious business depression which reached the proportions of a panic. A serious stock market drop began on March 13, 1907. Business failures in the midyear were followed by bank failures which rose to well over 200 in the year of this depression. The increase in the journal's capital stock had made it a safer business operation in view of the steadily increasing subscription list. In fact, it became necessary to engage a manager for The Surgical Publishing Company and provide him with a secretary, but their offices remained surrounded by the examining rooms and consulting offices of Martin, Kanavel and their colleagues. 2 Although he had not been invited to join, Franklin Martin had been impressed by the formation of the Society of Clinical Surgery on July 11, 1903. The society was started by a group of

2 Albert D. Ballou served as manager of The Surgical Publishing Company from April 1, 1907, to December 31, 1945. Fellowship of Surgeons 33 surgeons which included George W. Crile, Harvey Cushing, William J. Mayo and James G. Mumford. Later, other young, progressive surgeons over the country, among them John B. Murphy, became members. These men had become dissatisfied with the routine academic papers which were read at surgical meetings and which merely recorded what was happening. They had all encountered technical and mechanical problems in how to administer fluids to patients, how to insure smooth and safe anesthesia and a multitude of other practical questions had arisen in their minds. How better, they reasoned, could they differentiate between worthwhile procedures and the unacceptable than by watching actual demonstrations of technique in the operating rooms of their friends and colleagues. This was the kind of talk and action which Martin understood. These were the ways to disseminate surgical knowledge and instill in the minds of all surgeons a desire to contribute to the progress of the surgical care of the patient. In addition, this group of young surgeons was deeply interested in elevating the standards of teaching medicine to undergraduate students. So, at each of the semiannual gatherings, held in turn at the members' respective hospitals and medical schools, a part of the meeting was devoted to the methods of teaching medicine and the content of the curriculum. In 1904, the American Medical Association created the Coun- cil on Medical Education. Arthur Dean Bevan, a member of the Society of Clinical Surgery and The Chicago South-Side Medico-Social Society, was made Chairman. By 1907, the Council had compiled a complete list of the foreign medical colleges, and it was found that there were more medical schools in the United States than in all the other countries of the world. Later, tours of inspection were made to all medical schools by Abraham Flexner with the financial support of the Carnegie Foundation for the Advancement of Teaching. Flexner's report, Medical Education in the United States and Canada, with an introduction by Dr. Henry S. Pritchett, president of the Carnegie Foundation, was made on April 16, 1910. This report was to have a profound effect upon medical 34 Fellowship of Surgeons schools, the education of doctors and the training of those who wished to become surgeons. In part, it said: . . . it is a singular fact that the organization of medical education in this country has hitherto been such as not only to commercialize the process of education itself, but also to obscure in the minds of the public any discrimination between the well- trained physician and the physician who has had no adequate training whatsoever. As a rule, Americans, when they avail themselves of the services of a physician, make only the slightest inquiry as to what his previous training and preparation have been. One of the problems of the future is to educate the public itself to appreciate the fact that very seldom, under existing conditions, does a patient receive the best aid which it is possible to give him in the present state of medicine, and that this is due mainly to the fact that a vast army of men is admitted to the practice of medicine who are untrained in sciences fundamental to the profession and quite without a sufficient experience with disease. The significant facts revealed by this study are these: ( 1 ) For twenty-five years past, there had been an enormous overpro- duction of uneducated and ill-trained medical practitioners. This had been in absolute disregard of the public welfare and without any serious thought of the interests of the public. Tak- ing the United States as a whole, physicians are four or five times as numerous in proportion to population as in older countries like Germany. (2 ) Over-production of ill-trained men is due in the main to the existence of a very large number of commercial schools, sustained in many cases by advertising methods through which a mass of unprepared youth is drawn out from industrial occu- pations into the study of medicine. (3) Until recently, the conduct of a medical school was a profitable business, for the methods of instruction were mainly didactic. As the need for laboratories has become more keenly felt, the expenses of an efficient medical school have been greatly increased. The inadequacy of many of these schools may be judged from the fact that nearly half of all our medical schools have incomes below $10,000, and these incomes determine the quality of instruction that they can and do offer. Fellowship of Surgeons 35 Colleges and universities have in large measure failed in the past twenty-five years to appreciate the great advance in medical education and the increased cost of teaching it along modern lines. Many universities desirous of apparent education com- pleteness have annexed medical schools without making themselves responsible either for the standards of the professional schools or for their support. (4 ) The existence of many of these unnecessary and inadequate medical schools has been defended by the argument that a poor medical school is justified in the interest of the poor boy. It is clear that the poor boy has no right to go into any profession for which he is not willing to obtain adequate preparation; but the facts set forth in this report make it evident that this argument is insincere, and that the excuse which has hither- to been put forward in the name of the poor boy is in reality an argument in behalf of the poor medical school. (5 ) A hospital under complete educational control is as necessary to a medical school as is a laboratory of chemistry or pathology. High grade teaching within a hospital introduces a most wholesome and beneficial influence into its routines. Trus- tees of hospitals, public and private, should therefore go to the limit of their authority in opening hospital wards to teaching, provided only that the universities secure sufficient funds on their side to employ as teachers men who are devoted to clinical science. Perhaps in no other of the great professions does one find greater discrepancies between ideals of those who represent it. No members of the social order are more self-sacrificing than the true physicians and surgeons, and of this fine group none deserve so much of society as those who have taken upon their shoulders the burden of medical education. On the other hand, the profession has been diluted by the presence of a great number of men who have come from weak schools with low ideals both of education and professional honor. The apprentice saw disease; the didactic pupil heard and read about it; now once more the medical student returns to the patient, whom in the main he left when he parted with his preceptor. But he returns, relying no longer altogether on the senses with which nature endowed him, but with those senses made infinitely more acute, more accurate, and more helpful 36 Fellowship of Surgeons by the processes and the instruments which the last half- century's progress has placed at his disposal. This is the meaning of the altered aspect of medical training; the old preceptor, be he ever so able, could at best feel, see, smell, listen, with his un- aided senses. His achievements are not intended to be lightly dismissed; for his sole reliance upon his senses greatly augmented their power. Succeed as he might, however, his possibilities in the way of reducing, differentiating, and interpreting phenomena, or significant aspects of phenomena, were abruptly limited by his natural powers. These powers are nowadays easily enough transcended. The self-registering thermometer, the stethoscope, the microscope, the correlation of observed symptoms with the outgivings of chemical analysis and biological experimentation, enormously extend the physician's range.8 Franklin Martin's interest in medical education was always directed toward the graduate of medicine, not the undergraduate; but this report of Abraham Flexner struck a responsive chord. He had worked hard to keep doctors in practice up-to- date by offering good teaching and practical clinical demonstrations in the Post-Graduate Medical School. He realized fully that it would be better to continue training in surgery after the internship. By bringing the student into closer relationship with his patients, he could be taught to give complete surgical care under supervision and discipline. For a few, this is what Martin did. He was concerned that there was a multitude of licensed practitioners, the majority of whom had not even had an internship, but were operating and learning firsthand upon their patients. The problem was how to reach these men who could not be persuaded, or who did not have the means, to take a postgraduate course or spend the years necessary to serve as an assistant. If the Flexner report were accepted wholeheartedly by the medical schools, and if teaching of men to become surgeons became a part of the medical schools' direct influence upon their

3 Flexner, Abraham: Medical Education in the United States and Canada. A Report to the Carnegie Foundation for the Advancement of Teaching. Boston, D. B. Updike, The Merrymount Press, 1910. Fellowship of Surgeons 37 affiliated teaching hospitals, the problem of raising the standards of training for surgeons would ultimately be solved. But, he asked himself and his younger colleagues, what about the present and the immediate future? Can the principles of good surgical treatment be carried into the areas of the United States and Canada where there are no medical schools and few hospitals? Surgery, Gynecology & Obstetrics was one means of reaching those "near surgeons" who were so dangerous when they held a knife in their hand and stood beside the operating table upon which an anesthetized patient was secured. In the first issue, Nicholas Senn pointed out that iodine had demonstrated its effectiveness in sterilization of the patient's skin and in arrested suppuration of the knee joint. 4 Willis MacDonald placed upon the doctors and nurses the responsibility for the development of infection in clean surgical wounds .° The lively discussions which took place at meetings of the Mississippi Valley Medical Association and the Chicago Medical Society on the preferred type of operation for removal of the prostate gland were reported in the new journal's first volume. The readers were also given advice about prostatectomy from William T. Belfield, who concluded from his experience that because of its lower mortality, the perineal operation was preferred by most surgeons who devoted themselves to this special field of surgery, but suprapubic prostatectomy gave better results.° Robinson, as well as others, was attempting to find a way to anesthetize the patient and make it possible to open the chest cavity. He described a positive pressure cabinet for thoracic surgery after reporting his experimental studies.? Moynihan described his methods of ligating the inferior mesenteric vessels

4 Senn, Nicholas: Iodine in Surgery, With Special Reference to Its Use as an Antiseptic. Surg. Gyn. Obst., 1:1, 1905. 5 MacDonald, Willis G.: Practical Bacteriological Studies in the Surgical Clinic. Surg. Gyn. Obst., 3:216, 1906. 6 Belfield, William T.: Operative Treatment of Prostatic Hypertrophy. Surg. Gyn. Obst., 1:544, 1905. 7 Robinson, S.: A Positive Pressure Cabinet for Thoracic Surgery. Surg. Gyn. Obst., /0:287, 1910. 38 Fellowship of Surgeons for both the abdomino-perineal resection as well as the anterior resection of cancer of the left side of the colon. 8 A signed editorial by Emil Ries summarized the status of the radical operation for the treatment of cancer of the cervix of the uterus. Kanavel had insisted that readers of the journal should be able to judge editorial opinions for themselves if they were written over the author's signature. The new specialty of neurological surgery began to grow up, and the pages of the young journal were filled with contributions to the surgery of the nervous system. Cushing° described a decompressive measure for inaccessible brain tumors. Murphyl° wrote dogmatical- ly, as he taught in his clinic, about the surgical repair of periph- eral nerve injuries. Kanavel's contribution upon infections of the hand had not only been a "filler" for the budding magazine, but it was to be the beginning of an entirely new area to which surgeons were to devote themselves. The subscriptions to the journal had now reached around 3,500. The W. B. Saunders Company advertised the sixth edition of Da Costa's Modern Surgery; Parke, Davis & Company's advertisement spoke glowingly of "Soft Mass Pills Chocolate- coated (except #892) — which dissolve readily in the digestive tract. They are attractive in appearance. They keep well. They are absolutely true to formula." The H. W. Gossard Company called attention to "The Old Way and the New — Do You Wonder Why When you Compare Our Corset With Others?" Johnson & Johnson took a quarter of a page to say that "Red Cross Catgut preparation begins at the slaughter house and is conducted in a surgically clean laboratory by scientific methods, it is therefore Elastic, Pliable, of proper Tensile Strength, Sufficiently Resistant, perfectly Ab- sorbable and Absolutely Aseptic." A present day advertising

8 Moynihan, B. G. A.: The Surgical Treatment of Cancer of the Sigmoid Flexure and Rectum. Surg. Gyn. Obst., 6:463, 1908. ° Cushing, H.: The Establishment of Cerebral Hernia as a Decompressive Meas- ure for Inaccessible Brain Tumors; with the Description of Intermuscular Methods of Making the Bone Defect in Temporal and Occipital Regions. Surg. Gyn. Obst., 1:297, 1905. 10 Murphy, J. B.: Neurological Surgery. Surg. Gyn. Obst., 4:385, 1907. Fellowship of Surgeons 39 copywriter would undoubtedly be horrified by the punctuation and typography, to say nothing of the lack of display, in the advertisement. Perhaps it was the result of the alliance with the British editorial group which accounts for the acceptance of the Betul-ol advertisement for "a strictly ethical liniment for rheumatism, sprains, bruises, bronchitis, neuralgia and lumbago," manufactured by the Anglo-American Pharmaceutical Co., Ltd., of Croydon, London. It may have been that even then in the days of low printing and paper costs, advertising income was needed to permit the journal to fulfill its pledge "to make it a magazine which as a product of illustrated book-making (will be) chaste, adequate to its purposes, and artistic in appearance." All of these events apparently combined in the mind of Franklin Martin. He became convinced that hearing papers and reading articles in surgical journals were one thing, and some part could be absorbed by the listener and the reader. However, if young surgeons, the caliber of those who had founded the Society of Clinical Surgery, needed to see surgical operations performed to make these procedures become a part of themselves, certainly less well-trained but just as dedicated men, as anxious to learn and improve their talents, should profit by visits to the clinics of the outstanding surgeons. On a cruise in the Mediterranean in 1910, Martin's ideas took definite shape. Surgery, Gynecology dr Obstetrics, he said to his wife, had been successful beyond his wildest dreams; it had influence. He proposed that the journal invite its subscribers and others to visit the surgical clinics of Chicago, without dues or contributions of any kind. The journal would organize the clinics in the hospitals, invite the prominent surgeons of Chicago to participate and ask the hotels to furnish space for a headquarters. All of this he enthusiastically poured out to Isabelle as they paced the deck of the SS Arabic. He was nervous but prepared to meet any objection she offered. Isabelle had become reconciled to the surgical journal. In fact, she was as proud as he of its success. Possibly, Franklin thought, she had learned something about her husband's abilities in the 40 Fellowship of Surgeons meantime. This time Isabelle did not weep. Conservative as she always was, however, she was fearful that her agreement and sympathy with his plan might be an omen that it would not succeed. He pointed out that no harm would be done even if it failed. The invitation appeared as an editorial written by Franklin Martin in the September 1910 issue of Surgery, Gynecology & Obstetrics:11 . . . For five years this society ( Society of Clinical Surgery ) has quietly met several times a year in the principal clinical centers of the United States, and this year its members invaded Great Britain. During this time, there seemed to be no lagging of interest, and it is safe to say that its influence for good, both on the clinics visited and the visitors, as well as upon the surgical literature of the United States, exceeds that of many societies of much greater pretensions. It is the spirit of clinical investigation carried to the practical point of "show me." The idea has been growing for the last two decades. Clinical schools, where the work of a limited number of operators could be observed, have been organized and rather liberally patronized; also it has occurred to a few of the more progressive undergraduate schools to invite their alumni to a week of clinics each year at commencement time. The merited fame of several large surgical clinics, to which physicians were welcomed, has attracted surgical practitioners in greater and greater numbers for several years, until some of these clinics have become veritable surgical meccas. This tendency to learn by watching the actual work of the masters has become more and more popular, and the demand of the spirit this has engendered is for greater opportunities for clinical observation. If the technical skill of American surgeons, or those of any other community, is especially excellent it is because these surgeons are willing and anxious to learn by observing and being observed while actually at work in the operating room. This sort of training and observing has without doubt unhorsed a few literary and oratorical clinicians, but on the other hand it has brought to their proper perspective the hard-working, painstaking surgeons who make good.

11 Editorial, Surg. Gyn. Obst., 11:311, 1910. Fellowship of Surgeons 41 A recognition of the above facts, after duly considering their purport and the tendency of the times, has led the editors of Surgery, Gynecology and Obstetrics, in an endeavor to still further amplify the clinical idea, to invite to a clinical meeting, not a limited number to see the work of a few surgeons, but as far as practicable, every man in the United States and Canada who is particularly interested in surgery, to observe the principal clinics in one of the large medical centers. The initial test of this experiment will be inaugurated in Chicago, and the invitation is to be extended for the two weeks, November 7 to 19, 1910. The program ( see pages 17-19 of advertising section) will consist of operative clinics extending from 8 A.M. to 5 P.M. each day during the two weeks. Headquar- ters will be established at a central point where cards of admission to all clinics will be issued to visiting surgeons, and where each clay will be bulletined the clinics and demonstrations for the following twenty-four hours, thereby giving the visitor an opportunity to select his own program for the day. Six evenings of the two weeks will be given over to literary programs of surgical subjects conducted by the established societies of Chicago. These societies are preparing programs dealing with the practical live subjects in surgery, and the participants, who will be invited to co-operate with the Chicago surgeons, will be selected from the men in the United States and abroad, who are considered authorities on the particular subjects selected. The societies that will participate are the Chicago Medical ( two meetings ), the Chicago Surgical, the Chicago Gynecological, the Chicago Neurological and the Chicago Or- thopedic Societies. In working out the details of this undertaking the Editorial Staff must acknowledge the assistance and co-operation of the medical profession of Chicago, and especially the officers of its medical societies and the clinical teachers of its various hospitals and schools. FRANKLIN H. MARTIN, Managing Editor All of the expenses incurred in organization were to be borne :!ompletely by Surgery, Gynecology & Obstetrics. The journal )y now had been able to pay Martin's secretary for the time ;he spent on the affairs of the journal, engage Albert D. Ballou 42 Fellowship of Surgeons as General Manager of the business affairs, and pay the Man- aging Editor $200 a month from July 1, 1906, until the subscriptions reached 3,000. Invitations, totaling 10,000, were sent to those men listed in the directory of the American Medical Association who indicated their interest in practicing surgery, gynecology or obstetrics, their counterparts in the provinces of Canada and all the subscribers to the journal. As Martin said, "It was an innovation that the academic orators and medical politicians watched with amusement that they did not conceal; but it stirred in the minds of practical surgeons a hope that the advantages of the Society of Clinical Surgery were now to be extended to all progressive specialists." Most of the criticism came from Chicago, and from within the South-Side Medico- Social Society, led by Frank Billings and Arthur Dean Bevan, his fellow members. The following month an editorial announcement appeared: 12

THE CLINICAL MEETING The reception accorded the preliminary announcement of the Clinical Meeting arranged for the surgeons of North America by the editors of Surgery, Gynecology and Obstetrics to be held in Chicago, November 7 to 19, 1910, has been so gratifying that we predict a representative and enthusiastic attendance. Our arrangements are such that a large number of visitors can be comfortably cared for, both as regards hotel accommo- dations and the various clinics. By consulting the program ( see announcement in advertising pages) it will be observed that a dozen or more important clinics will be in operation simultaneously, and since many of them are in commodious amphithea- tres or operating rooms, there need be no fear of undue crowding. The clinical material is abundant. Every branch of surgery will be represented by a number of clinics. These are to be bulletined daily, twenty-four hours in advance, giving the details of operative procedures or demonstrations. This will allow the visitor to specialize in any branch and to keep himself busy

12 Surg. Gyn. Obst., //:430, 1910. Fellowship of Surgeons 43 throughout the day in observing work in which he may have a particular interest. Auditoriums of suitable size and acoustic properties have been engaged for the literary sessions which will be afforded by the medical societies of Chicago, and ample provision made for all visitors to hear and see. On account of the strictly scientific object of this clinical meeting no effort has been made to provide special social functions for those attending the meeting. Chicago always has many features in the way of sights, instruction, entertainment and amusement, and November is a particularly auspicious time to visit the city for these attractions. Physicians bringing their families will have ample opportunity, since every other evening is left free, to attend the opera, the concerts, the theatres and other places of amusement with them. The ladies, likewise, will find much to interest them in the shopping district, the parks, the galleries, the women's clubs and theatres. Two hundred visitors had been forecast by the staff of the ournal who were to man the registration headquarters, list the :linics and operations for each day, issue tickets of admission and suggest points of interest for the wives who accompanied heir husbands. The booths for registration in the La Salle Hotel vere overrun by 1,300 doctors, seeking tickets to the clinics of heir choice, and under-manned by the journal's staff which had

:o be increased by volunteer assistants. Each operating room ;allery and surgical amphitheater at the hospitals which chose o participate in the clinical congress had been visited and its !apacity set by Ballou. An exact number of admission tickets vas issued, and Murphy's large amphitheater clinic which held i00 was soon filled. Smaller operating rooms, presided over by nore modest and less well-known surgeons, expanded to the mrsting point. Martin didn't believe in doing things by halves. He offered a 'ull two weeks' program when a less confident entrepreneur night have been happily satisfied to have whetted his visitors' appetites with a week of activity rather than run the gamble surfeiting even the most eager seeker after learning. Appar- 44 Fellowship of Surgeons ently, there was no flagging of interest or enthusiasm on the part of either the visitors or the hosts. As doctors do, the visitors came to know each other, traded anecdotes and expressed themselves about their experiences in the hospitals of Chicago. There was a strong movement to effect an organization which would insure a repetition of the sessions. On Friday afternoon, November 18, 1910, the day before the program was to end, Dr. James Beaty Eagleson of Seattle, Washington, acted as the chairman of a meeting of the visitors. The discussion was opened by Franklin Martin, who in answer to a question by Dr. J. A. Williams, of Greensboro, North Caro- lina, said that there were surgical societies, gynecological societies and one clinical society of surgeons, but there had never been a meeting like the one they were attending. A large number of men had been able to witness clinical work by a group of prominent surgical teachers working at the same time in their respective hospitals. Martin emphasized that demonstrations, instead of talk and reading of papers, was the strong characteristic of the meeting. "It differs from the usual society," he said, "in its greater comprehensiveness. It admits everybody to see the work of a few." Since Murphy's clinic had been the most popular, and his amphitheater the largest, Martin wanted to be sure he would attend the rump business meeting. There was never any time when Franklin Martin lost sight of the opportunity to keep the interest at an enthusiastic level by stage-managing an entrance. Murphy had been elected president of the American Medical Association, and as he entered the room after the meeting had been in progress, the audience rose and applauded him. He responded with a short, stimulating speech in his high-pitched voice about the new era in surgery and reminded his audience that the organization which they were there to create should be started correctly by electing a leader of clinical surgery as President. In glowing terms, Murphy spoke of the outstanding surgical qualifications of a candidate he wished to suggest to them, a man who was a friend and whom everybody loved and respected—Dr. Albert J. Ochsner. There was evidently some Fellowship of Surgeons 45 hesitation at such an abrupt and precipitous action. Character- istically, Murphy pointed to someone in the audience and said, "You second the nomination." A standing unanimous vote made Ochsner the first President of the newly created clinical organization." It was quickly decided that the name of the society should be "The Clinical Congress of Surgeons of North America." It would hold its meetings at "one of the large clinical centers of North America annually." Its membership would consist of all reputable surgeons who were subscribers to its official organ and those who registered each year at its regular meetings. Martin's political interests must have dictated that "The executive and elective body shall consist of representatives chosen each year as follows: one from each congressional district of the United States and two representatives at large from each state; one from each parliamentary district of Canada, and two at large from each province of Canada; two from Mexico and each Central American republic, two from each colony of the United States and two from each of the government departments, the Army, the Navy, and the Marine Hospital Service."" An anonymous writer in Surgery, Gynecology & Obstetrics summarized the first clinical meeting: 15 From the first morning, when several hundred registered and rapidly scattered to the well known clinics of Ochsner, Murphy, Bevan, Frank and others, and later in the day to Cook County Hospital, Rush, Physicians and Surgeons, and the North- western University medical schools, until the curtain was rung down on Saturday evening two weeks later, there was no sign of flagging interest or enthusiasm on the part of the visitors or on the part of those conducting the clinics. All surgical Chicago caught the spirit of hospitality, and the large hospitals, such as Michael Reese, St. Luke's and Wesley, prepared programs for

13 John G. Clark of Philadelphia was elected Vice-President, Franklin H. Mar- tin became General Secretary and Editor, Allen B. Kanavel was made General Recorder and Treasurer and Albert D. Ballou, General Manager. 14 Organization of the Congress. Surg. Gyn. Obst., 11:623, 1910. 15 A Report of the First Meeting of the Clinical Congress. Surg. Gyn. Obst., 11:622, 1910. 46 Fellowship of Surgeons certain days where clinics and demonstrations were given by relays of prominent operators extending almost continuously from morning till night. Borderline clinics were given in which interesting unison work was done by the surgeons working in conjunction with prominent internists and pathologists. The individual demonstrations on cystoscopy, blood-vessel surgery, transplantation of bone, transplantation of organs, intestinal suturing, gunshot wounds of the intestines, blood transfusion, etc., given before small classes, were interesting to those interested especially in experimental surgery. At the end of the first week of the meeting, its acceptance had become so obvious that a group of surgeons from Philadel- phia sent John B. Roberts to Martin with an invitation to hold the next meeting in their city. Martin wisely delayed making a decision hastily because he hoped that plans for a permanent organization would originate from the visiting doctors. More- over, he was not completely sure that Dr. Roberts represented the majority of the outstanding surgeons and obstetricians in Philadelphia. He promised to visit Philadelphia later and discuss the matter with a representative group from that city's hospitals and medical schools. All of the expenses of the staff work, mailing the invitations, printing the tickets and renting the headquarters space, to the amount of $2,500, were borne by Surgery, Gynecology dr Ob- stetrics.° This could not be continued and, therefore, it was decided to charge a fee of $5.00 for registration at the second Congress. Martin lost no time in accepting an invitation to visit Phila- delphia in December to discuss a proposed congress for the next year. John G. Clark, an outstanding gynecologist, invited Martin to a dinner at his home on December 6 to meet with a group of eminent clinicians of Philadelphia." After dinner, Martin gave an account of the Chicago meeting, which the ebul- See Appendix, Chapter 2:1. 16 Dr. Clark had invited Drs. John B. Roberts, Edward Martin, Robert G. Le- Conte, Barton Cooke Hirst, William L. Rodman, George E. de Schweinitz, Edward P. Davis, William Ashton, J. Montgomery Baldy, Charles H. Frazier and John H. Gibbon to his home for dinner to meet with Franklin Martin. Fellowship of Surgeons 47 lient Roberts described as "a miracle meeting." Martin enthusiastically told of the object of substituting an exclusively clinical meeting for the literary programs with volunteer papers and discussion which had prevailed. An effort should be made to democratize surgical teaching and education. Every medical graduate was entitled to an opportunity for furthering his education, personal observations and mental and technical equipment. He should be able to obtain these goals from any source at which they might be found, whether or not that source had been recognized by previous achievement. In other words, Mar- tin said that the unknown surgeon in the city in which the Congress was held should have an audience if he had a mission, a word to give, or a demonstration to make. He could be scrutinized by a group of discriminating practical surgeons and, if his work and theories stood their testing inquiries, his future would thereby be helped regardless of his previous prestige or inherited opportunities. It should be the purpose of the future Congresses to make everyone in attendance feel that the organization was interested in making him a better surgeon and that, in turn, the organization should be assured of reciprocal support from the attendants. November 7 to 16, 1911, was set as the time for the second Clinical Congress in Philadelphia by the committee on arrangements, under the chairmanship of Dr. Clark.* Again, the preliminary clerical work was done by the staff of The Surgical Publishing Company, and the same pattern of clinical demonstrations and operations was followed. Fifteen hundred doctors registered, but because of confusion in carrying out the details by the host doctors, a generous estimation was made that at least that many more attended without paying the $5.00 registration fee. There were widespread rumors that the registration fee was the source of personal income for Franklin Martin. A group agitated to have the subscription price of Surgery, Gyne- cology 6 - Obstetrics entitle the subscriber to attend the Congress without paying a registration fee. These doctors argued that they were members of the Congress automatically because they ° See Appendix, Chapter 2:2. 48 Fellowship of Surgeons were subscribers. Martin, himself, had written this fact in the invitation to the first meeting. Complaints arose on overcrowd- ing in the operating rooms and charges of favoritism from the host clinicians and the members. In a frank and direct statement to those who attended the business meeting on November 13, Martin said that he hoped that every man who subscribed to the surgical journal had done so with the idea that he would get $5.00 worth of magazine "without any side prize package of any kind." He called their attention to the large number of "floaters or deadheads" who were attending the clinics. He urged the registrants to police the clinics themselves, wear the identifying buttons which had been provided and protect the host clinicians and their own rights from the interlopers.* On November 13, when the meeting had been in session a week, the Treasurer, Allen Kanavel, reported to the members that the bills for the 1910 Clinical Congress held in Chicago were paid in full by Surgery, Gynecology & Obstetrics. He detailed the expenses to date, emphasizing that the receipts from registrants were $4,230 and that the expenses would unquestionably exceed that amount. The last sentence in his report was significant in the light of the gossip—"No salary has been paid to any officer."* As Secretary of the Clinical Congress, Martin gave a report filled with enthusiasm and compliments for the Philadelphia hosts. He became eloquent. "We have had an opportunity in these few days of witnessing the greatest teachers of surgery working in an environment of the greatest teaching institutions of our country. . . . Can we go home to our own hospitals, to our own teaching institutions, and to our own classes, be as well satisfied with them, if our hospitals are inadequate, our teaching institutions unequipped, and our students deficient in educational opportunities in comparison with those that we have admired here?" He urged them to appoint representatives who were actually doing surgery and he spoke loosely of ° See Appendix, Chapter 2:3. " See Appendix, Chapter 2:4. Fellowship of Surgeons 49 "United States Senators and members of the House of Repre- sentatives" among them, even though "our constitution prescribes no definite legislative duties for our representatives.* The matter of receipts and expenses was again brought up at a business meeting, and it was suggested from the floor that an assessment be made upon the members to cover a deficit. Martin objected to this method: I would be very much averse to making an assessment of any kind upon the members and I do not believe it will be necessary to increase the registration fee. I believe if we had received the fees of men who are attending this Congress and who did not pay, if we had been a little more strict, we would not have bad a deficit, and I believe that ( this) matter, with our experience of this year, will be adjusted next year. It is simply a matter of experience. No one can believe that a man would come across the Continent to attend clinics under the auspices of an organization and get out in some way of paying the fee. Dr. Baldy, one of the members of the local committee on arrangements said that his group had raised twelve or fifteen hundred dollars to pay the rental for a good many of the halls. He was sure that the local committee wished to have that money expended. After a free discussion which was often as far away from the point under consideration as is customary among large gatherings of doctors, the entire question was left to the executive committee of the Congress for solution. Isabelle, who had accompanied Franklin to Philadelphia, pointed out to him as he walked the floor of their hotel room in the Bellevue Stratford that large organizations composed of individuals and subdivided into committees are usually be- deviled by jealousy, secretiveness and other human weaknesses. She told him that he shouldn't expect to have any one of the committees completely efficient or to have every action always the expression of a well and deeply laid design. In spite of all the irritations and defects, the clinics were well conducted and the visitors were enthusiastic. Nearly 2,000 doe- * See Appendix, Chapter 2:5. 50 Fellowship of Surgeons tors attended the first evening meeting which was given under the auspices of the Philadelphia County Medical Society and was held in the Egyptian Room of the John Wanamaker Build- ing. A symposium of papers on "The Surgery of the Upper Abdomen" was presented by Drs. J. F. Binnie of Kansas City, George E. Brewer of New York City and Maurice H. Richard- son of Boston. W. L. Rodman, Robert G. Le Conte and John B. Deaver of Philadelphia discussed the papers and the evening was completed with a reception and a recital on the "magnificent organ that is one of the features of the beautiful Wana- maker Hall." Albert J. Ochsner gave his presidential address on "The Co- ordination of Undergraduate and Post-graduate Teaching of Clinical Surgery" in the ballroom of the Bellevue Stratford Hotel on the next evening. The Academy of Surgery, the Pe- diatric Society, the Obstetrical Society and the Neurological Society of Philadelphia provided interesting evening meetings which were held in the new home of the College of Physicians. These sessions were described later as "perfections of detail and worth in their scientific arrangements, and the setting in that palace of medicine was an inspiration to everyone who was fortunate enough to attend the Congress." There was extensive coverage of the clinics in the daily newspapers: The special tickets which are required for admission to the clinics conducted by Dr. John B. Deaver have not been sufficient for the demand the two days the Congress has been in session. Surgeons from distant parts of the United States are fully acquainted with Dr. Deaver's reputation. . . . The doctor performed 13 operations yesterday at the German Hospital, several of them of a difficult nature. The Philadelphia Press headlined its Friday morning story on November 10: "Man's Kidney Transferred To Living Dog," "New York Surgeon Tells of Wonderful Operation Saving Ani- mal's Life," "Dr. Mayo on Cancers." Dr. Alexis Carrel gave an illustrated lecture on the technique and results of blood vessel Fellowship of Surgeons 51 astomosis and explained the transplantation of a human kid- y in a dog which lived for two years afterward. The North American of November 10 was extravagant in its scription of John B. Deaver's clinic: Throughout four and one-half hours of surgical work requiring the keenest knowledge of technique and an eye and hand that would not flag in the minutest detail, even for a moment, Dr. John B. Deaver stood in the clinical amphitheater of the German Hospital yesterday afternoon and demonstrated to a throng of surgeons from all over the continent his methods in general surgery. It was an evidence of skill and breadth of knowledge seldom called for in the general practice, for of the nine different forms of operations, not one resembled the other. Yet every case brought to the operating table was disposed of within a few moments of the time set by previous calculations, and the admiration and applause of his fellow-operators were stifled into half-utterances as one flashing set of instruments was laid aside and another taken up for a more difficult case. The Philadelphia Inquirer reported on Saturday morning, No- mber 11, that Dr. John B. Deaver had operated upon "Pitch- Coombs of the Athletics, who was injured while pitching ainst New York during the world's championship series, for repair of a hernia." The Philadelphia Record of November reported Dr. John H. Gibbon's operation on a child with a ngenital deformity of the intestinal tract—"Anastomoses was rforrned, uniting the part of the canal on each side of the isted colon and forming a veritable 'short circuit.' " In the ne story, it appears that Dr. John B. Deaver had a busy day rforming 16 operations, "which probably will stand as a ree- 1 for the Clinical Congress." Dr. Ernest La Place and Dr. Wayne Babcock, both of Phila- 1phia, provided good copy for The North American in a con-. wersy over the indications and the use of spinal anesthesia. I have to be operated on by a surgeon, I want no needles my spine," said Dr. La Place. "Then you would consider surgery under spinal anesthetiza- 52 Fellowship of Surgeons lion merely a semi-merciful form of human vivisection, would you not?" Dr. La Place was asked. "That is about what it amounts to," he replied. These were strong words uttered by men of definite opinions in 1911, who quite obviously never objected to standing up and being counted. An item of publicity which appeared in The Philadelphia Record on November 14 brought respect and honor to the surgical profession: "I have received no formal offer of the presidency of Prince- ton and consequently I have not accepted the position," said Dr. J. M. T. Finney, of Baltimore, last night in discussing the published reports that the presidency had been formally ten- dered him. "I would feel greatly honored at being asked to head the institution of which I am a graduate, and the news that my name was being considered seriously was a complete surprise to me," he continued. "I cannot discuss the matter further. You know that I am a trustee of Princeton and it places me in a peculiar position." There was entertainment for the wives of the busy surgeons. Isabelle Martin heard Madame Schumann-Heink in concert with the Boston Symphony Orchestra and saw "The Trail of the Lonesome Pine" which starred Charlotte Walker. On November 11, Franklin Martin received a night letter from Dr. LeRoy Brown of New York City: Dickinson, Studdiford, Wells and myself are coming to Phil- adelphia Sunday to talk over next year's meeting of the Con- gress and New York as the place. We are all enthusiastic. At what hour can we meet you at the hotel? Wire me one forty eight west seventy seventh street. This was not the only group who wished to consult Martin about naming New York City as the next meeting place. Three other groups appeared and Martin thought at first that each was antagonistic toward the other. The Congress in Philadelphia ended with the election of Fellowship of Surgeons 53 Edward Martin as President and George E. Brewer of New York City, Vice-President. Franklin Martin and the other officers were re-elected, and New York City was designated as the meeting place for the third Clinical Congress. Brewer was made chairman of the committee on arrangements and Dr. Charles H. Peck, secretary." The Waldorf-Astoria was selected as the headquarters, and the Congress was set for November 11 to 16, 1912. Martin thought about the coming New York meeting a great deal and was anxious to avoid any unpleasantness or division of loyalty to the Congress. He invited the spokesman of each of the four groups and four of his colleagues, whom he was to select, to have lunch with him at The Waldorf-Astoria to discuss preparations for the session that fall. He soon learned that the groups had had little personal contact with each other even though they were members of many of the leading national surgical societies and of the local surgical organizations. No one of those present at the luncheon from New York City had previously met all of the other New York luncheon guests. They were unanimous, however, in wishing to make the third Clinical Congress of Surgeons better than those which had preceded it. Ellsworth Eliot, Jr., Howard C. Taylor, Howard Lilien- thal, George D. Stewart, Lewis S. Pilcher, John F. Erdmann, E. L. Keyes, Jr., J. Bentley Squier and Alfred S. Taylor were some of the surgeons who were added to the local arrangements committee after the luncheon meeting. A month prior to the meeting, which had now been reduced to a week in length, a preliminary program was published in Surgery, Gynecology & Obstetrics, reprinted and distributed widely. Advance registrations pointed to the largest attendance and seemed to justify the promotional copy: Every indication points to a large and enthusiastic meeting for the third session of the Clinical Congress of Surgeons of George Woolsey, John 0. Polak, J. W. Markoe, Le Roy Broun, Brooks Wells, Arpad Gerster, R. L. Dickinson, Willy Meyer and Robert Morris were named to the committee during the Philadelphia session. 54 Fellowship of Surgeons North America to be held in New York City the week of No- vember 11 to 16. The completed program which appears on the following pages is comprehensive in its scope and extremely attractive from a scientific standpoint. Naturally, the most attractive feature to surgeons is the enormous clinical schedule. . . . In addition to the operative clinics an excellent program of demonstrations in radiology, surgical pathology, experimental surgery and kindred subjects has been prepared to make a complete showing of New York's facilities as a surgical center. In the list of clinicians will be found the names of the leading surgeons of New York City and Brooklyn, and in the list of institutions that have opened their doors to the Congress are the leading hospitals and medical schools of the two great cities. Every branch of surgery is covered. . . . For the evenings there will be six literary sessions at which papers dealing with subjects of live surgical interest will be read by prominent surgeons of America and Europe, and these will be discussed by New York surgeons. . . . During the afternoon of each day of the session there will be bulletined at headquarters a complete and accurate program of the clinics and demonstrations to be held the succeeding day. These bulletins will be displayed on large boards in the grand ball-room. Also a printed program will be issued daily, announcing all clinics, demonstrations, scientific evening programs, business meetings. Any physician or surgeon in North America in good standing may become a member of the Congress by registering at any annual meeting and paying the registration fee of $5.00. Auto- matically the subscribers to Surgery, Gynecology and Obstetrics, the official journal of the Clinical Congress, are members of the Congress and will receive invitations without request. To other members of the profession who desire to attend the Congress, formal invitations will be sent if they will address a communication to the Secretary of the Congress. A registration fee of $5.00 is required of each surgeon at the time of registration, whereupon a membership card will be issued. Unlike conditions prevailing in most medical societies, where annual dues are required, payable by each member without Fellowship of Surgeons 55 regard to his attendance at any meeting of the society, the payment of a registration fee is required of a member of the Con- gress only when he is in attendance at an annual session. The purpose of this fee is to provide funds to meet the expense of preparing for and conducting the annual meeting in order that the Congress may not impose a financial burden upon the members of the profession in the city entertaining the Con- gress. Judging from past experience the amount received from such fees will be barely sufficient for the purpose, so that payment of the fee is expected of all who register. It will be absolutely necessary for each surgeon who desires to attend the clinics or evening literary sessions to register at headquarters and secure a membership card. This card must be presented to secure admission to the clinics and evening sessions. . . .

An innovation of demonstrations, or dry clinics, in contrast to operative clinics, would be formally introduced at this third session. Leo Buerger agreed to discuss the pathology of thrombo- angiitis obliterans at the Mt. Sinai Hospital; Francis C. Wood was scheduled to demonstrate interesting surgical specimens and methods of recording surgical material at St. Luke's Hos- pital; George D. Stewart and Arthur Wright would present problems pertaining to experimental surgery at the University and Bellevue Hospital Medical College; George S. Huntington, Professor of Anatomy, and W. G. MacCallum, Professor of Pathology at the College of Physicians and Surgeons, were asked to lecture and demonstrate upon specimens of the structure and development of the genitourinary tract with special reference to surgical conditions and the results of studies in experimental pathology, including cardiac pathology, diseases of the organs of internal secretion and cancer studies. John R. Murlin would demonstrate and discuss the headless cat as a subject of physiological experiment in a session at the Cornell University Medical College. Here were stimulating opportunities to be offered to practical surgeons, as Martin expressed it, to broaden their base upon scientific facts which were being discovered in labora- 56 Fellowship of Surgeons tories. The attendance at Dr. Murlin's demonstration may have been discouraging, but the mere fact that these physiological experiments were offered to such a gathering of surgeons was the initial step which could lead to the development of surgery as the art of the application of knowledge gained in the basic medical sciences. Martin realized fully that at the moment surgery was largely a manual art; that the operation was considered to be the thing and that operative technique was the most important qualification of the surgeon. Preoperative preparation of the patient was limited largely to rest in bed until time might make the patient a better surgical risk. Postopera- tive care was empirical and concerned the condition of the wound more than the patient as a whole. Failure of peristalsis of the bowel following an abdominal operation was commonly treated with a tenth of a grain of calomel every 15 minutes until a fatal termination. To provide continuing education for the large group of surgeons who were attending the sessions, it was imperative that they first be brought to the trough of clinical surgical methods. Gradually then, the enriching diet could be added. The rather informal and loose organization of the Clinical Congress obviously was to be strained to its limit at the New York meeting. Certain surgeons with well-organized clinics in teaching hospitals and the heads of departments in medical schools refused to be scheduled in the program with a number of smaller clinics which they believed to be inferior. The latter just as strongly and vehemently insisted that they should be included. A satisfactory solution had to be found if the idea and organization were to survive. Attendance at popular clinics was not limited to the registered members or even to those who had in the order of first come, first served, designated it as their choice. Some means of controlling the attendance at each clinic had to be found, and hospitals had to co-operate to recognize tickets as a requirement for admission to a clinic. The serious problem, however, was to determine the acceptability of the standards and ethics of the clinicians and the men who wished to attend. Fellowship of Surgeons 57 Accreditation of physicians and surgeons had existed in Great Britain for centuries. It was associated with licensing because the accrediting bodies had the authority by law to issue licenses to practice. Martin realized that in the United States, the licensing of physicians had been in effect just over 50 years, and it was a function of state governments exclusively. Though the standards and requirements of the states varied tremendously, a license to practice medicine was still a form of accreditation, though it was the lowest form to be sure. Every individual with a license to practice, regardless of his education or training, had the right to perform operations. Even though Surgery, Gynecology & Obstetrics had financed the first meeting completely and had paid a deficit of $2,000 for the second session, Franklin Martin, because he owned 51 per cent of the stock of The Surgical Publishing Company, was accused of making a financial bonanza out of the Clinical Con- gress. It appeared that this coming third Congress might be self- supporting and that monies advanced by the publishing company could be repaid. A separation of the Clinical Congress accounts must be established and statements issued which would be audited by certified public accountants. Franklin Martin realized that in less than three years his original ideas and plans had been outgrown. On the Twentieth Century Limited en route to the New York meeting, Martin has said that he conceived the idea of a new organization through which definite qualifications for membership could be established. He wished to take advantage of the Clinical Congress organization, but the confusion which had resulted from the attendance of nonregistrants was serious. Those who considered themselves qualified surgeons wished to discriminate against others. If he could establish a society upon the framework of the Congress, he could accomplish what was needed to save this promising adventure in the continuing education of surgeons. He dictated his ideas to the train stenographer, put the typewritten sheets in his pocket and slept on his ideas hoping he would have even more mature thoughts upon arriving in New 58 Fellowship of Surgeons York.18 He had written down five proposals from which could develop a college of surgeons of the United States and Canada. They were stated simply: 1. A standard of professional, ethical, and moral requirements for every authorized graduate in medicine who practices general surgery or any of its specialties, in so far as feasible along the lines of the Royal Colleges of Surgeons of England, Ireland, and Scotland. 2. A supplementary degree for operating surgeons. 3. Special letters to indicate fellowship in the college. 4. A published list of members of the college. 5. The appointment of a committee of twelve members of the Clinical Congress with full power to proceed with the plan, if careful consideration proved its worth. Martin rushed to The Waldorf-Astoria and called John B. Murphy's room. He was anxious to try out his ideas upon the one man he knew would listen sympathetically and yet be logical in his suggestions or opposition. The proposals were read by Martin, sitting on the tub in Murphy's bathroom as the latter continued to shave. Martin did not have to wait long for Murphy's reaction, which was an enthusiastic approval. In fact, Murphy asked for the privilege of seconding Martin's presentation to the Clinical Congress. The next few days were hectic as Martin discussed with Murphy, Ochsner, Edward Martin and others the personnel of the organization committee of 12. Edward Martin had a personality equally as striking as Franklin Martin's. He was direct in his speech and often was regarded as being autocratic. He was an enthusiastic supporter of the clinical meetings which had been initiated in Chicago and was keenly aware of the criticisms and confusion in the understanding of purpose which had resulted from the Philadelphia meeting. He listened carefully to Franklin Martin's elaboration of his ideas as they stood among the exhibits surrounded by a milling group of peripatetic doctors avidly seeking to improve themselves in their profes-

18 Martin, F. H.: The Joy of Living—An Autobiography. New York, Doubleday, Doran & Co., 1:410, 1933. Fellowship of Surgeons 59 sion. "Ned" Martin bubbled over with his approval and rather condescendingly, Franklin thought, urged him to "go the limit." Franklin Martin needed some time to crystallize his ideas so he could present them logically and fluently at the last business meeting of the Congress. Besides, there was plenty to be done at the business meeting on Tuesday, November 12. He had entered into an agreement with the editors and Julius Springer, the publisher, of the new Zentrailblatt fur Chirurgie and the new Zentrallblatt fur Gynecologie, the official organs of the German Surgical and Gynecological Societies, and with Masson & Cie, publishers of the Journal de Chirurgie, for the purpose of establishing an International Abstract of Surgery which was to be a part of Surgery, Gynecology & Obstetrics. Dr. J. Bentley Squier presented a resolution, unanimously passed, which commended and confirmed "the agreements and understandings entered into with these foreign organizations." The resolution also wished "to emphasize our loyalty to and support of this new progressive enterprise of the editor of our official organ." This action provided for an exchange of journals from which articles could be abstracted and constituted an act which in Martin's opinion gave the flavor of an international society to the Clinical Congress. In the years to come, it provided one of the most popular features of the "blue" surgical journal. Then, there were the amendments to be made to the constitution which was a simple instrument adopted in Chicago, discussed and argued over in Philadelphia. Articles IV, V, VI and VII were the ones in which the members were most interested.* They provided that the election of officers and conduct of business should be under the direction of representatives to be known as "Congressional and Senatorial Rep- resentatives." This feature had been introduced at the Chicago meeting and Martin had referred to the "Representatives" in . Philadelphia, but no provision had been made to elect them. Now it was spelled out so that those in attendance from each state, each province of Canada and each independent republic • See Appendix, Chapter 2:6. 60 Fellowship of Surgeons of Central America, the United States territories, the Army, Navy and Marine Hospital Service would assemble and elect their representatives from among those present for a term of two years. If for any reason representatives were not so elected, the Executive Committee would then appoint them. The Exec- utive Committee was to consist of the officers of the Congress and the last six ex-Presidents. Article X made Surgery, Gynecology & Obstetrics the official organ of the Clinical Congress. With the interest which Frank- lin Martin had always shown in politics, it is not strange that he should think in terms of his own United States Congress to obtain a democratic form of government for the new organization. He saw no reason why there should be any jealousies exhibited over who was a Senatorial representative or just a Congressional representative. They were equal honors, he thought, even though there were fewer Senatorial Representa- tives. Franklin Martin had held his bombshell for the Friday afternoon business session to be held at five o'clock on November 15. President Edward Martin recognized the Secretary who reported that 2,600 doctors had registered for the Congress. Mar- tin went on to say that if the attendance increased proportionately in the coming two years, it would tax the hospitality of any city in the world and become prohibitive. "Therefore," he said, "the point is already forced upon us to begin to consider the advisability of limiting the membership of the organization." He again made it quite definite and clear that with the registration fee of $5.00, Surgery, Gynecology & Obstetrics would not be included. However, he was not prepared to say that doubling the registration fee to the Congress would make it possible to include the official organ. This would be a matter for the Executive Committee to consider. He urged that those in attendance make application for membership in the "permanent limited organization to the General Secretary in Chi- cago, at the earliest possible date. . . ." The Secretary was ahead of the business at hand in soliciting members for an organization which had not been proposed, let alone adopted. Fellowship of Surgeons The other Martin was not a dull-witted presiding officer. Im- mediately, he called upon the Secretary to proceed, whereupon Franklin Martin after a somewhat discursive preamble which touched upon the need for a society like the Clinical Congress, the success of the three meetings which fulfilled the primary object sought in the meetings and the origin of the Congress by the editors of the surgical journal, finally came to the point. "To be more definite, I believe that this largest organization of surgeons on the American Continent, the Clinical Congress of Surgeons of North America, should assume the responsibility and the authority of standardizing surgery." What Franklin Martin probably meant was not to standardize surgery but to establish a minimum standard of requirements which a graduate of medicine should possess if he aspired to perform surgical operations. All of the ideas he had been dreaming about were stated in five resolutions which he presented to those in attendance as a motion: First — It should formulate a minimum standard of requirements which should be possessed by any authorized graduate in medicine, who is allowed to perform independently surgical operations in general surgery, or any of its specialties. Second — It should consider the desirability of listing the names of those men who desire to practice surgery, and who come under the authorized requirements. Third — It should seek a means of legalizing under national, colonial, state or provincial laws, a distinct degree supplementing the medical degree, which shall be conferred upon physicians possessing the requirements recognized by this law as necessary to be possessed by operating surgeons. Fourth — It should seek co-operation with the medical schools of the continent which have the right to confer the degree of M.D. under the recognized standards, and authorize these colleges to confer the supplementary degree of Surgeons on each of its graduates as have, in addition to their medical course, fulfilled the necessary apprenticeship in surgical hospitals, operative laboratories and actual operative surgery. Fifth — It should authorize and popularize the use of this title by men upon whom it is conferred, and its use should espe- 62 Fellowship of Surgeons cially be urged in all directories of physicians, in order that the laity as well as the medical man can distinguish between the men who have and the men who have not been authorized to practice surgery. This was an audacious and completely new thought and after he had made his five points, Franklin Martin continued. The time was ripe, he said, for a concerted action on the part of thinking surgeons to insist that future surgeons be thoroughly educated and trained under the direction of practical surgeons before they were legally or morally allowed to operate upon the public. The unsuspecting patient, without any way of dis- tinguishing between a trained surgeon and a tyro, would be protected. Further, it would protect the would-be surgeon against his own inexperience and put a premium where it belonged on the trained, conscientious surgeon. Then, in his enthusiasm, he made a great understatement; he said that he appreciated the practical difficulties which would arise in carrying this innovation into successful execution.* Finally, he moved that the President be authorized to appoint a committee of nine members, of which the President and his immediate predecessor should be two members, to consider the advisability of studying the resolutions and "with power to act in any manner the committee may wish." John B. Murphy called the resolution "comprehensive, timely, important and protective to surgeons and the public," as he seconded the motion. The motion was carried unanimously viva voce. The committee was appointed by Edward Martin. It consisted of nine members plus the outgoing and the President to be elected, making a total of 11 instead of nine. This was not all to be accomplished at this third Clinical Congress meeting. President Martin had ideas, too, for the good of surgery. He enlisted the services of Allen Kanavel to introduce a resolution which was to form one of the pillars upon which the nebulous "College of Surgeons" was to rest. Edward Martin knew that owing to the rapid development of surgery throughout the country, there had been a rapid increase in

• See Appendix, Chapter 2:7. Fellowship of Surgeons 63 hospitals. Unfortunately, many hospitals did not have equipment necessary to allow the proper performance of surgical operations. It was true, also, that many hospitals were conducted in a manner which brought discredit upon the medical profession. President Martin thought it possible to standardize hospitals in such a way that the public could know to which hospitals they could go with safety.* Frederic Besley seconded Kanavel's motion to adopt the resolution which empowered President Martin to appoint a committee to carry the spirit of the resolution into effect. 19 Finally, Dr. Southgate Leigh, then President of the Virginia State Medical Society and of the Tri-State Medical Society of Virginia and the Carolinas, introduced a resolution which would authorize the President to appoint a committee of five to disseminate information, by a "campaign of publicity," about the early symptoms of cancer of the uterus.** Dr. Leigh's resolution had been presented in writing and was adopted in his absence from the meeting. President Martin had appointed Thomas S. Cullen of Baltimore as chairman, Howard C. Taylor of New York, C. Jeff Miller of New Orleans, F. F. Simpson of Pittsburgh and E. C. Dudley of Chicago as the committee. Later, Southgate Leigh, from the floor, presented another resolution which would increase the membership of the committee and extend its scope to include a campaign of education among the laity with respect to the signs and symptoms of all forms of cancer. The time was getting late. There were resolutions to be presented thanking the hosts for their hospitality, and a nominating committee was to report that Dr. George E. Brewer be made President and Dr. W. W. Chipman of Montreal be elected Vice-President of the Clinical Congress. Dr. Leigh's resolution was lost in the confusion of parliamentary procedures and besides his original idea had been adopted. True, he had not been named to the committee. Franklin Martin was so intent upon the formation of a Col-

19 Ernest A. Codman of Boston was appointed Chairman with William J. Mayo, Allen B. Kanavel, John C. Clark and W. W. Chipman as members of the Com- mittee on the Standardization of Hospitals. ° See Appendix, Chapter 2:8. 0 ° See Appendix, Chapter 2:9. 64 Fellowship of Surgeons lege of Surgeons that he did not appreciate the possibilities of the motions to standardize hospitals and to disseminate information about cancer until a few years later. It was natural to look upon the committees as groups which might not be able to accomplish a great deal but which would at least represent activities of the new organization. The men appointed to the committee to act upon the formation of a College were the important ones. Some of them he did not know personally, so he had consulted as many sources as he could in the relatively short time available. In the end, he had relied upon Murphy and Ned Martin principally to choose men who had some vision and would work. It wouldn't take him long to find out if they would work and not just talk, he thought, as on the train going home he reviewed for Isabelle what he did know about them. "George Brewer will be a good President," Franklin told Isabelle positively. "He's only 51 years of age and received his Bachelor of Arts and a Master of Arts degree from Hamilton College where he played the chapel organ. He's a Harvard man in medicine and received his training at the Boston City Hospital. Then he went to the Columbia Hospital for Women in Washington, D. C. He is Professor of Clinical Surgery at Physicians and Surgeons here in New York. He's written a textbook of surgery and another on surgical diagnosis. From all I hear, he has simplicity and intellectual honesty and is unselfish."" "I heard some of the doctors say what an inspiring clinic he gave," said Isabelle, "and I thought he was very courteous and kindly. Dr. Chipman of Montreal is attractive, Franklin." "Of course, all you women would think so. Chipman is 45 and handsome. He's a Nova Scotian by birth and is now Professor of Obstetrics and Gynecology at McGill. He took five years of

20 Conversational dialogue is based upon repeated talks with Franklin and Isa- belle Martin about the beginnings of the Clinical Congresses, Surgery, Gynecology 1.7 Obstetrics and the American College of Surgeons from 1925 to Dr. Martin's death in 1935 and Mrs. Martin's death in 1945. Their personal diaries have been available for reference. Fellowship of Surgeons 65 postgraduate training in Edinburgh, Berlin, Vienna and Paris. He's a Fellow of the Royal College of Surgeons of Edinburgh, the oldest college. He'll understand what I have in mind." "Do you think, perhaps, you may have too many young men? Dr. Cotton can't be 50, and George Crile is only 48." "Just right. I'm the oldest, then Ochsner, Matas and Ned Martin. Cotton was born in Wisconsin, you know. He was educated on the Atlantic seaboard just because his father was a civil engineer and traveled east on his jobs. He's a Harvard graduate all the way through. He received a Master of Arts degree automatically because he ranked high in his medical school class. He had his internship at the Massachusetts Gen- eral and then studied in New York and Vienna. He is an orthopedist. They tell me he's quite a showman in his class teaching, has a clever choice of words and draws on the blackboard as he talks. I guess already he's poured some oil on the ever- present troubled waters in the medical community of Boston." "You know, Franklin, I became quite well acquainted with Grace Crile and had nice quiet talks with her and George while you were rushing around with your coattails flying. He has such an active and curious mind and such charming cheerful- ness. His wife seems to keep up with a kind of driving vitality. He'd be a loyal friend, Franklin." "I know, I know." Sometimes he became impatient with Isa- belle when she intimated that he hadn't thought things through. "George Crile is self-made. He left home when he was 15 to teach a village school and he taught between the times he went to Ohio Northern University and the Wooster Medical School in Cleveland, so he could pay his way. He had an internship and did postgraduate work in Vienna, Berlin and London. He has an inquisitive mind, all right; he's writing about shock, hemorrhage and blood transfusion. You heard his talk the other evening on anoci-association, didn't you?" "Yes, I did, but I didn't understand a word of it. Did you?" "Well, in parts, I did. He made them think though, didn't he? J. B. is strong for Finney of Baltimore. You remember, he's the fellow who was considered for the presidency of Princeton, 66 Fellowship of Surgeons and it was in the paper last year when we met in Philadelphia. He was born in Natchez, Mississippi; his father was a Presby- terian minister. He's a Princeton man but graduated in medicine from Harvard and was at the Massachusetts General as an intern. Halsted, Professor of Surgery at the Hopkins, gave Finney an appointment on his surgical staff in charge of the dispensary the day the hospital opened. Murphy says he's a simple man with direct courage and honesty. He has a sense of humor, which certainly helps the son of a minister. He's one of the young ones you talk about, just 49." "That reminds me, Franklin. Were you able to convince Dr. Murphy he should serve on the committee?" Martin grimaced and shook his head. "Yes, but we had a hard time getting him to accept. I wanted him in the worst way and dear Ochsner joined me in trying to convince him he must be on. He said Ochsner belonged on the committee because he was a past-President and that I belonged there because I had the idea and would do the work. If he were on, it would be overloaded with Chicago men and would draw criticism. Then that honest Irishman looked us both right in the eye and said, `You both know I have too many enemies to do you any good. I'll be with you — get on with it.' He has just finished his term as president of the A.M.A. and I think that had something to do with his reluctance. I finally convinced him that his name would carry great influence over the country." "Dr. Matas is such a gentle, sympathetic man, isn't he? What a reader he must be and such a wonderful memory. He's so unhurried and thorough in his conversation. If he gives his medical speeches the same way, he might be difficult to stop." Isabelle had the most distracting habit of changing the subject so quickly and completely. She had apparently accepted the Murphy decision and considered the matter closed. Maybe he had better do the same. "Rudolph Matas comes from Spanish parents and his father was a physician. He graduated from the Literary Institute of St. John's in Matamoras, Mexico, it says about him on this card Fellowship of Surgeons 67 I have. He received his Doctor of Medicine from the Univer- sity of Louisiana, now Tulane University, in 1880. He's 52, just three years younger than I. He's familiar with music, painting, sculpture and reads the literature of five languages." Martin paused and looked at his wife with a smile. "He's a bachelor, too." There was silence for a while as he shuffled the typewritten cards through his hands. "Why did you choose Dr. Charlie instead of Dr. Will Mayo?" The woman was uncanny. He had Charlie's card in his hand. He knew all about his graduation from the Chicago Medical College, his alma mater, now Northwestern University. He had thought a great deal about this one choice between the brothers who had remained with their physician father in the little town of Rochester, Minnesota, their birthplace, to practice their profession. Will was the precise organizer and the blue- eyed disciplinarian who made their famous Clinic work efficiently. Charlie was awkward and shy and spoke in a low, soft, hesitant drawl. He took people and institutions as they were, tried to improve them as he could but seemed to accept grace- fully that perfection was not possible. Franklin Martin judged him to be a keen observer and a fair critic without prejudices. All of these factors had influenced his decision. He answered his wife briefly and rather cryptically, she thought. "By taking Charlie on the committee, we'll have both Charlie and Will. Charlie is a better man on a committee." Isabelle nodded her agreement, and Franklin was somewhat surprised that he did not have to argue the matter further with her because he knew of her great admiration and affection for the older of the brothers Mayo. She often said that he reminded her of an Indian; he was so erect and his likes and dislikes were so positive but once a friend, he was unswerving in his loyalty. "Who will represent the far West, Franklin? So far, the geo- graphic distribution in the committee is excellent." "Rixford. Emmet Rixford from San Francisco. He wasn't at the meeting and I don't know him. He has a good reputation 68 Fellowship of Surgeons and was graduated from the University of California in engi- neering before he went into medicine. He's only 47 years old. I'll have to make a trip out there to get acquainted." That left Ochsner, another Wisconsin-born man, and Ned Martin. Like Crile, Ochsner had taught rural and grade schools to provide himself with enough money to go to the University of Wisconsin where he had earned his Bachelor's degree. He had graduated from Rush Medical College and while in attendance had helped teach histology and embryology. He had a tremendous practice among the Swedish population of Chi- cago and, in his white tie and frock coat, with his gold watch chain, long blond hair and gold rimmed eyeglasses, looked like a minister. He was honest, Martin was sure, even though many unkind things had been said about his methods of obtaining a large practice and his technical dexterity which, it was said, had made him lose all sense of the danger of a surgeon's knife. He would be a faithful wheel horse. Ned Martin, he had decided, hid his real self behind a facade. He appeared to be absent-minded; once wore tan shoes with his white tie and tails. His old battered green hat was a signature. Proud with his Quaker convictions, he adopted a casual and humorous air of pretending to be completely oblivious of general opinion. There they were, a fine choice of men interested in the best of surgery. Isabelle interrupted his meditations. "I have finally found a quotation in my book of poems and famous quotes that I want to read to you, Franklin. Then you must promise not to talk about your plans any more till tomorrow. Now, listen. This was said by Edmund Burke. 'Those who would carry on great public schemes must be proof against the worst fatiguing delays, the most mortifying disappointments, the most shocking insults, and, worst of all, the presumptuous judgment of the ignorant upon their designs.' Come now, its time to go into the dining car." CHAPTER 3

OHN B. MURPHY'S eloquent and inspiring speech seconding j the motion to organize a College of Surgeons had brought a standing ovation from the 2,500 surgeons who attended the third Clinical Congress in New York. Franklin Martin realized fully that procrastination and delay would handicap the successful completion of the plan. He knew that the 11 men who had been appointed to the organizational committee were strong personalities. Immediate action was necessary to formulate details of procedure and policy around which they could crystallize their individual ideas. In- terested as they were, he knew there were those among them who would hesitate to translate thoughts and ideas into action when they comprehended fully the enormity of the task. It appeared evident to Martin that the interest shown in the Clinical Congresses by the surgeons who attended made clear the necessity for a large democratic society, or guild, of surgeons. Through such an organization there could be an exchange of ideas and methods which would elevate the standards of surgery throughout the North American continent. Diversity in the work of surgeons in the three cities where the meetings had been held revealed that there were no existing standards to follow in learning to become a surgeon. Specialization in surgery had begun and new problems were arising rapidly. New discoveries were being made so quickly that no one individual could keep pace. The surgical procedures in fashion developed a vicious competition which led to unethical practices. Too often the patient was operated upon first and his illness diagnosed later. The hospitals in which the surgeons worked furnished a wide variety of facilities which ranged from bad, or indifferent, to inadequate. The bewildered 70 Fellowship of Surgeons public was totally unable to determine who was a conscientious, competent surgeon and who was not. Martin believed that there was a need for an organization of surgeons, which would be built around the demonstration of proper surgical diagnostic methods and procedures. It would promote research into surgical problems, preserve inviolate the moral and ethical principles of surgical practice and encourage and set standards for the training of young surgeons. It would attempt to maintain a high degree of standards in the hospitals in which surgery was performed. Finally, it would provide a list, which would be easily accessible to the public, of the names of those doctors who were adequately trained and competent surgeons and who would pledge themselves to support these principles. After interviews and conversations with the members of the committee, Martin had worked out a preliminary plan of organization. He, Murphy, Ochsner, Edward Martin and Brewer obtained incorporation papers for the American College of Sur- geons from the State of Illinois on November 25, 1912. 0 Thus armed, Martin went to a meeting of the Organization Commit- tee at Old Point Comfort, Virginia. This coincided with the annual meeting of the Southern Gynecological and Surgical Association.' Martin's plan proposed that the founders of the corporation should be selected from members of the faculties of all of the recognized undergraduate and postgraduate schools of medicine in the United States and Canada and from a list of such other surgeons as the existing organizational committee might designate. He proposed that an executive committee of 15 or more should be elected by the corporation at its first meeting. Pro- vision was to be made whereby they would be divided into classes with terms of service terminating in one, two and three • See Appendix, Chapter 3:1. 1 The Southern Gynecological and Surgical Association later was renamed the Southern Surgical Association. This meeting was held December 17-19, 1912, at Old Point Comfort, Virginia. C. H. Mayo, Crile and Finney were members who were present. Martin was an invited guest of the Association. Finney gave his presidential address at this meeting. Fellowship of Surgeons 71 years, as their successors were selected. This executive committee would be known as the Board of Governors and their duties would correspond to a board of trustees. Franklin Martin suggested that the members, or Fellows, as they were to be known, should be chosen from the several thousand surgeons of whose standards of practice there could be no doubt. A second group was to consist of other graduates of medicine who would qualify themselves as surgeons according to the requirements of the College. A third group would include younger graduates in medicine, who could meet the requirements of the College by virtue of the completion of supplementary work directed by their own medical school. Fellow- ship was to be conferred at regular convocations by the corporation upon recommendation of the Board of Governors. The prospective members, therefore, were those men agreed upon as being surgeons, those who practiced surgery but who would have to prove their abilities and those who would aspire to become surgeons. Martin wished to leave the qualifications for the latter group entirely to the decision of the universities and medical schools. He suggested to the committee that they should immediately select four to five hundred names from the tentative list which he had prepared. Each of the chosen prospects would then be visited by a member of the committee and urged to attend an organization meeting on the evening of May 5, 1913, at the New Willard Hotel in Washington, D. C., where the Congress of Physicians and Surgeons of North America was scheduled to meet during the following week. Though disappointed, Martin was not surprised to find that his fellow committeemen expressed their alarm at the apparent haste, which he believed necessary, and at the thought of the work and travel which each one of them would be called upon to do. However, he had come prepared. His next suggestion was that, as Secretary, he should compile for the approval of the committee a list of the leading cities of the United States and Canada and of the outstanding surgeons in those cities. If the committee desired, he would visit the cities at his own 72 Fellowship of Surgeons expense and present the plan of the proposed organization. The committee received and approved these suggestions with aston- ishing rapidity and cordiality. Baltimore, Washington, Philadelphia, New York, Brooklyn and Boston were chosen to represent the Atlantic seaboard. Toronto, Montreal, Vancouver and Winnipeg were named for Canada. Los Angeles, San Francisco, Portland and Seattle were selected on the Pacific coast. Minneapolis, St. Paul, Kansas City, St. Louis and Chicago rounded out the list of cities which Martin would visit. In each of the cities, a member of the Organization Committee, or local men chosen by the committee, were to arrange a meeting at which Martin could explain and answer questions. The plans would be presented to men in other sections of the country by correspondence or by less formal personal contact. Martin neglected his professional practice and began his journey. The first meeting was held in Baltimore in January of 1913 and was arranged by Finney, a member of the Organization Committee. Martin's spirits were dampened considerably when Finney inquired as to what he should do at the meeting. Finney said that he did not have a clear idea of the object. Martin had not had close personal association with him but had acquired respect for his straightforwardness and integrity. He knew that he would have to convince him before Finney would lend his complete backing. Martin wondered why he had agreed to serve on the committee if he were not convinced of the ideals and aims of the plan for a College of Surgeons. Martin knew he must not be impatient with men who thought more slowly and arrived at decisions less hastily. Without preliminaries, Finney introduced Martin and sat back to listen with the rest of the 30 men he had invited to assemble in the committee room of the Baltimore Academy of Medicine. It was an uninspired talk which Franklin Martin gave to an unsympathetic audience. He was heckled after he had haltingly extended an invitation to them to attend a meeting in Washington to discuss the advisability, or inadvisability, of establishing a surgical association dedicated to attain a higher Fellowship of Surgeons 73 standard of surgery and establish a means whereby the laity could discriminate in the selection of a qualified surgeon. He attempted to explain by pointing out a parallel with the Royal Colleges of Surgeons of England, Edinburgh and Ireland. Later, this analogy was to haunt him. In answer to the hecklers' statements that universities were attempting to accomplish the things which the new association contemplated, Martin said that they needed help from a representative group of surgeons, many of whom were not teachers but were strong supporters of high standards in medical education. In rebuttal, he admitted that he did not know why the American Medical Association wouldn't carry out the purposes which he had proposed and asked, "Are they doing it?" Each man in the audience had taken the card, which Martin had given him to sign and return if he desired an invitation to the meeting in Washington. Finney brought the meeting to a close by saying that he did not know a great deal about the proposal but thought it should be considered carefully. Discon- certedly, he added that they should go slowly before commit- ting themselves. The opening gun had been fired, but the can- non had turned out to be a cap pistol. Martin's sad disappointment was lightened slightly by the fact that about a dozen men rather surreptitiously handed their signed cards to him as they left. He realized for the first time how much of an uphill fight it might be to gain wholehearted support for ideals which he was convinced would elevate the standards and quality of the art of surgery. On he went to Philadelphia where his spirits were raised by his good friend, John G. Clark, who had invited a group of surgeons to his home for dinner. The surroundings, excellent food and drinks augured well for a good meeting with a more captive audience. Martin concluded that passing out cards for signa- tures might be an efficient way of making a record of those interested in the Washington meeting but such a procedure had been and could be interpreted as high pressure salesman- ship. The fine dinner, the charming host and Edward Martin's in- 74 Fellowship of Surgeons troductory remarks put Franklin Martin on his mettle. He was determined to profit from the humiliating experience he had suffered in Baltimore the previous evening. He spoke with facility and conviction. The College of Surgeons should be inclusive, not exclusive, in its methods of choosing members. It should be democratic, with its Fellows chosen for ability and practical accomplishments, rather than represent an exclusive aristocracy based upon position and reputation deserved or un- deserved. Martin emphasized that the principal object should be to elevate the standards of surgery by utilizing the administrative machinery of existing teaching institutions and hospitals in order that prospective Fellows could obtain proper surgical training. It was necessary that surgeons of prominence become members in order to emphasize the importance of the College to the young men who aspired to become surgeons and to the practicing surgeons who could be educated further. The latter group must be induced to qualify and seek the stamp of approval of the College. The ceremonies of the College in granting Fellow- ship should be impressive and dignified in order to increase its prestige with the surgical profession and the laity. To that end, proper newspaper and medical journal publicity should be encouraged. In John Clark's home, Franklin Martin knew he had sympathetic listeners, even though his audience might not have been unanimous in its approval. In his ardent presentation, he did not make a clear distinction in importance between the arguments which he elaborated. He suggested that a blue book, or directory, listing the names and addresses of Fellows by states and cities, should be published each year. It would serve as a guide for the laity to choose qualified surgeons. It was proposed that the finances of the corporation should be independent and a Founder's fee of $25.00 should be charged. A fee of $10.00 should be established for Fellows admitted after the Founder group was closed. No annual dues would be necessary because of the Fellowship fees obtained each year. The subscription price of $2.00 for the directory would be an extra item. Fellowship of Surgeons 75 Since the College of Surgeons was to bring its influence to bear by co-operating with medical schools and societies presently existing and the medical schools and hospitals were all properly chartered under state and provincial laws, the only charter that the College of Surgeons would require would be one obtained "not for pecuniary gain" under a state law. This step had already been taken by the Organization Committee, Martin announced. Robert G. LeConte immediately complimented Martin upon his lucid explanation, and LeConte's motion to approve the plan was promptly seconded. However, the motion did not have smooth sailing. Without at first indicating serious opposition, John H. Gibbon developed the argument that such an organization would establish a class distinction in the United States in imitation of European methods which were distinctly undemocratic. "Ned" Martin, whose sense of humor often created a diversion which was not entirely harmless, facetiously questioned Gibbon's sincerity. Aroused by Edward Martin, Gibbon finally announced in no uncertain terms that he was opposed to the whole plan and would stay out of it. Others tried to dispel the impression which Gibbon's opposition had created. Franklin Martin has reported rather impressively that John Chalmers Da Costa said that he, too, would think twice before supporting the plan? Realizing that the meeting might get out of hand, Martin stated that the point at issue was whether or not some, or all, of those present thought well enough of the plan to go to Washington and meet with several hundred surgeons to discuss the advisability of establishing an American College of Surgeons. The motion was approved over two distinctly audible negative votes. 3 Martin's experience in New York City could have completely discouraged a less persistent crusader. George E. Brewer,

2 Martin, F. H.: The Joy of Living—An Autobiography. New York, Doubleday, Doran & Co., 1:415, 1933. 3 An application for Fellowship was sent to Dr. Gibbon on September 10, 1913, and again on June 6, 1921. He was, therefore, invited to be a Founder Fellow and later a Fellow without the necessity of establishing his qualifications. On May 10, 1922, the chairman of the Credentials Committee of Pennsylvania stated that Dr. Gibbon did not wish to join the American College of Surgeons. 76 Fellowship of Surgeons Charles H. Peck, J. Bentley Squier and Joseph D. Bryant, the latter of whom had operated upon President Grover Cleveland, were members of the large committee. Martin had been told that about 100 surgeons had been invited to attend the meeting at the Academy of Medicine. Peck and Squier met him and took him upstairs to an empty meeting room. Eventually, Bryant arrived and sarcastically commented upon doctors who accepted committee obligations and never fulfilled their responsibilities. After 12 or 15 men had finally assembled, Bryant assumed command. He asked Martin a few direct questions about the plan, was apparently satisfied with the answers and predicted that it would be a success. Without further ado, Bryant proposed that those present approve the organization of a College of Surgeons, elect a chairman and secretary and thus put New York on record as supporting the proposal. This was done. Before adjournment, Bryant suggested that on the following morning each absentee should be informed by telephone of the important meeting and notified that the plan was favorably received by those present. With one exception, each surgeon whom Martin was able to reach profusely regretted his inability to be present and authorized his name to be placed on the list. When Martin informed him of the morning's work, Bryant made no comment except to laugh heartily and wish him further success. Martin's original anticipated fears for a successful meeting in Boston were magnified by his experiences in Baltimore, Phila- delphia and New York. Frederic Cotton dispelled them with a dinner in his home to which he had invited Dean Edward H. Bradford of the Harvard Medical School and Dean Horace D. Arnold of the Graduate School of Medicine. Both of these men were sympathetic to the plan. The two Deans and the other members of the local committee, with Cotton and Martin, occupied the platform at the Academy of Medicine. Martin's presentation was brief and orderly. Harvey Cushing and others commended the fundamental ideals of the plan and were encouraging. A standing vote unanimously accepted the invitation Fellowship of Surgeons 77 to attend the Washington meeting. Cotton gave Martin a list of the names of all the men present, and this short but most businesslike meeting was over. A small group went on to one of Boston's finest restaurants and Martin's day was completed with an informal social gathering. Martin returned to Chicago and his professional practice for about six weeks and then began his trip to the Pacific Coast in March 1913. The meeting in Los Angeles was arranged by Granville MacGowan. John B. Murphy, who was in the city at the time, played no small part in making it a complete success. Martin's reception in San Francisco was the opposite. Emmet Rixford had been unanimously selected as the west coast representative of the Organization Committee, though he had not been present at the Clinical Congress in New York City. When Cooper Medical College had become a part of Stanford Uni- versity in 1909, Rixford had continued as the Professor of Surgery. Martin had received no replies to the numerous letters he had written him about the coming meeting, but after arriving in San Francisco and after experiencing considerable difficulty in reaching him, Martin learned from Rixford that a meeting had been called. Martin arrived at the meeting hall alone and did not know any of the early arrivals, nor did they know him. He sat alone in the front of the long, narrow room at the side of a raised platform. Finally, a stranger sat down beside him, inquired if he were Dr. Martin and apologized for the tardiness of the "Big Four." These men, he said in response to Martin's question, were Rixford, Thomas Huntington, Stanley Stillman and Harry Sherman. The young stranger called Martin's attention to the fact that the hall was filled with young surgeons associated with the University of California and Stanford University medical schools. Huntington and Stillman shook hands with Martin as they passed, but Rixford and Sherman went to the platform with only a nod of greeting. Rixford's introduction was brief. Martin told the audience that Dr. Rixford and he were members of an organizational committee appointed at the Clinical Congress 78 Fellowship of Surgeons in New York to consider the advisability of establishing a Col- lege of Surgeons for the United States and Canada. His succinct presentation was patterned after the Boston speech. He said that he was there on behalf of the committee to extend an invitation for them to attend a meeting in Washington, D. C., in May and to answer such questions as they might ask which would help them form an opinion about the plan and their participation in it. The silence became oppressive as he sat down. Rixford declared the meeting adjourned inasmuch as there were no questions or remarks. He did remind the audience that Martin was the Editor of Surgery, Gynecology & Obstetrics, of which he had every reason to be proud. As the "Big Four" left, Martin stopped Sherman, introduced himself and said that he had heard a great deal about him from George Crile, George Brewer and the Mayos. He also thanked Sherman for being one of the first subscribers to the struggling surgical journal. The latter nodded, turned on his heel and left the room. As Martin went into the street, he was rescued by a group of the young men who had been present. He was happy to accept their invitation to return him to his hotel. Instead, they took him to a restaurant where they were joined by several others. They stayed late as he answered their questions and talked about the plan of a College of Surgeons. These men resented the method in which the San Francisco meeting had been held and wanted Martin's assurance that they would not be eliminated from the Washington meeting. The meeting in Portland, arranged by Robert C. Coffey, An- drew C. Smith and Ernst A. Sommer, the one in Seattle, sponsored by James B. Eagleson, and the one in Vancouver, organized by Robert E. McKechnie, were unqualified successes. On the way home, Martin stopped at Minneapolis, St. Paul, Kansas City and St. Louis where the reception of the plan was wholehearted. He had left the meeting in Chicago to the last because he believed that the criticisms, which were gaining more and more circulation, originated in his home city, though the attacks had not as yet come out into the open. The support which he had gained in the cities visited Fellowship of Surgeons 79 would be a powerful deterrent to the attempts to embarrass him within the committee on organization. The criticisms appeared to center around the supposition that a new association was being organized which would usurp the functions of the American Medical Association. This same objection had been raised to the founding of the American Surgical Association. In fact, it had been said that organizing the American Surgical Association was an attack upon the American Medical Association which intended to destroy its influence as the representative body of the medical profession. It was claimed that all of the objectives sought by such an association could be accomplished through the Section on Surgery of the American Medical Association. There had been many discussions of the rights of surgical specialists compared with the rights of general practitioners. The economic, scientific and social aspects of specialization were attracting increasing attention. In his address of welcome at the meeting of the American Surgical Association in Philadelphia on May 18, 1882, Samuel Gross, the first president, said, "If it be said that we are striking a blow at the American Medical Association, we deny the soft impeachment. On the contrary, we shall strengthen that body by rousing it from its Rip Van Winkle slumbers and infusing new life into it. We can hurt no society now in existence, or likely to come into existence. We can hurt only ourselves if we fail to do our duty. We hope to make the American Surgical Association an altar upon which we may annually lay our contributions to surgical science and so show the world that we are earnest and zealous laborers in the interest of human progress and human suffering." Local jealousies quickly came into the open because the proposed College of Surgeons was a larger and less exclusive organization proposed by a Chicagoan. Here 31 years later, it was argued again that the American Medical Association was the proper society through which elevation of surgical practice should be accomplished. The fact that nothing had been done and no initiating steps had been taken by that association had 80 Fellowship of Surgeons been pointed out by Martin to a questioner in his audience at Baltimore. He could have answered more eloquently by quoting Cross' words. It had been more disturbing, however, to read a news item in the April 1913 issue of the California State Medical Journal, written by its editor, Dr. Philip Mills Jones: Dr. Franklin H. Martin, of Chicago, has been out here on an expedition to organize the "American Royal Institute, or College, of Surgeons," the latest national Murphy advertising adventure. Martin did not know Jones. As far as he was aware, the editor had not attended the meeting in San Francisco. He looked up previous issues of the journal, which had an excellent reputation, and found that Jones that same year had written an editorial in the January issue entitled, "A New Year Prayer." In it, he wrote, "Let no word of idle slander or sup- posititious criticism of a colleague pass your lips; if you cannot speak well of a brother physician, speak not at all, for when you disparage another physician you hurt yourself as well and the entire profession is belittled in the eyes of the people." The inconsistency of the editor intrigued Martin. He found that Jones, born in Brooklyn, was 43 years of age. He was graduated from the Long Island Hospital College of Medicine at the age of 21 and had practiced in Brooklyn until 1900 when he moved to California. There, he had joined the faculty of the University of California in the Department of Archaeology. Jones had played a prominent part in the reorganization of the Medical Society of the State of California and became its secretary and the editor of its journal. Finally, he gained credits for a degree in law so that he might be more conversant with the many medico-legal and economic problems which the state association was facing. He represented his state organization in the House of Delegates of the American Medical Association from 1903 to 1908, when he was elected a member of the Board of Trustees. Martin wondered if his cool reception in San Fran- cisco had not been inspired by Jones, who as a delegate had been opposed to the election of John B. Murphy as president of the American Medical Association in 1911. Fellowship of Surgeons 81 Martin had worked hard to prepare detailed plans of organization, including proposed bylaws, an order of business and proper resolutions. He wanted to submit these topics for discussion by the Organization Committee of 12 which was to meet on the morning of May 5, 1913, at the New Willard Hotel in Washington. Only Rixford from San Francisco and Charles Mayo were absent. This meeting, in effect, was a rehearsal for the meeting of a larger Committee on Committees to be held that afternoon at two o'clock. Fifty-seven men met with the committee of 12. 0 Edward Martin, the chairman, announced that the object of the meeting was to formulate further and to endorse, if those present saw fit, the work of the Organization Committee in developing a plan "in regard to the standardization of surgery, the benefit of the profession and the protection of the public." The secretary, Franklin Martin, explained that the Organiza- tion Committee wished to go over the plan with them in detail before presenting it to the 300 surgeons who would be present at a meeting that evening. He stated that those assembled represented different state groups with whom lie had met on his trips and with whom he had corresponded. He added suggestively that if they could endorse the plan, it would facilitate business at the larger meeting to be held at eight o'clock that evening. Every detail of the agenda for the later meeting was read. After the call to order by Edward Martin, the chairman of the Organization Committee, the secretary of the committee would read the formal call for the meeting. It would then be in order to elect a chairman and secretary. The next item of business would be to consider the advisability of organizing a continental association of surgeons which would have for its object the encouragement and maintenance of a higher standard of surgery. Approval of such a motion would naturally lead to the presentation of bylaws one by one. After their approval, a motion to adjourn the meeting of the corporation and convene a meeting of the proposed Board of Governors would be in order. • See Appendix, Chapter 3:2. 82 Fellowship of Surgeons Chairman Martin ruled that the secretary should read the proposed bylaws so that questions, criticisms and suggestions could be made by the Committee on Committees. The group listened patiently and intently. 4 The incorporation papers granted by the State of Illinois named the American College of Surgeons, but the bylaws specified the College of Surgeons, a concession which Franklin Martin had made to the various opinions he had received while on his travels. The object of the College should be to "elevate the standard of surgery, to provide a method of granting fellowships in the organization, and to formulate a plan which will indicate to the public and to the profession that the surgeon possessing such fellowship is specifically qualified to practice surgery as a specialty." The general management of the corporation would be vested in a Board of Governors which, in turn, would delegate the details of the management to a board of trustees to be known as the Board of Regents. The original Board of Governors, it was proposed, should consist of 500 surgeons invited by the Organization Committee of 12 to serve as Founders of the Col- lege. This power, placed arbitrarily in the hands of 12 men, to affix the stamp of approval upon 500 surgeons was the obvious point of attack by opponents of the idea. It would be asked—Who are these omniscient men to whom this power should be entrusted? That this was a mechanism by which an organization could be started seemed a simple concept to Franklin Martin, even granting that mistakes in judgment might be made. It was a starting point, however, and would be modified and changed as Article 2 of Section IV of the bylaws would show. This provided that the original Board of Governors should be divided by lot into three classes to serve one, two and three years, respectively. At the annual meeting in 1914 and each year thereafter, the Fellows of the College would elect from their membership, in a manner to be determined by the Board of Regents,

4 The first bylaws adopted appear in the first yearbook of the American Col- lege of Surgeons, 1913, p. 9. Fellowship of Surgeons 83 50 surgeons to the Board of Governors, each for a term of three years. Two candidates should be nominated by the 15 leading surgical societies and associations of North America. Twenty Governors would be elected at large to represent those surgeons who were not members of the surgical societies. Even- tually, the Board of Governors would consist of 150 Fellows of the College. Likewise, the Board of Governors at its first meeting should elect 12 from among its own members to be Regents. These should be divided into three classes of four members each, whose terms of office should expire in one, two and three years. To give countries other than the United States representation on the Board of Regents, it was stated that not more than three of each class should be elected from one country. The Presi- dent, General Secretary and Treasurer would be members of the Board of Regents during their terms of office. The officers of the College were to be elected for a term of one year by the Board of Governors from among the Fellows of the College. The General Secretary's duties would be to keep all records of the corporation, as well as meetings of the Board of Governors and the Board of Regents. In addition, he was to have general supervision of the business affairs of the corporation under the direction of the Board of Regents. This delegation of responsibility and authority to the Secretary formed the basis for the attacks upon Franklin Martin's power in the new organization and upon his integrity. The Regents, it was claimed later, were only puppets who acted as he directed. There were fewer occasions on which to appoint committees in 1913, and perhaps it was not commonly understood that the work of committees is usually accomplished by the energetic efforts of one man. Graduates in medicine, who were licensed to practice, could apply for Fellowship. Their application had to be endorsed by three Fellows, one of whom was a Governor. All applicants were to meet the requirements for Fellowship which would be established and modified from time to time by the Board of Regents. Election to Fellowship would occur only by vote of 84 Fellowship of Surgeons the Board of Regents after recommendation by the Committee on Credentials elected by that Board. Expulsion for unprofessional or any other conduct inconsistent with the rules and regulations could be accomplished by a majority vote of the entire Board of Regents. The Fellow so charged would be invited to appear before the Board to hear and defend the charges made against him. The 57 men present from representative cities in the United States and Canada discussed each bylaw. Questions were raised by Caspar W. Sharples of Seattle about the indefiniteness of the term, "Fellow of the College of Surgeons." He and his fellow townsman, Guy S. Peterkin, also objected that the North Pacific Coast Surgical Association was not one of the surgical societies from which Governors would be elected. Herbert A. Bruce of Toronto, J. Wesley Bovee of Washington, D. C., Charles A. L. Reed of Cincinnati, John Wesley Long of Greens- boro, North Carolina, Frederick W. Marlow of Toronto and John R. Wathen of Louisville argued definitions and representation vigorously. The staunchest supporter from Philadelphia, LeConte, suggested that they not take hasty action and pointed out that it took two years to form the American Surgical Association. He rose, he said, simply to ask for advice as to whether or not they should attempt to complete the organization at the time. The chairman, Edward Martin, answered him. It was a provisional program, he said. To accomplish anything, it was necessary to provide a program upon which discussion could be centered and action taken. Undoubtedly, it would take months to perfect a working basis for the organization. At eight o'clock that evening of May 5, 1913, the Organization Committee appeared before the more than 300 surgeons from all parts of the United States and Canada who had accepted the invitation to participate in the discussion of the advisability of forming such an organization and the procedural methods proposed to accomplish that purpose. The secretary of the committee read the call for the meeting.° The two Martins were ° See Appendix, Chapter 3:3. Fellowship of Surgeons 85 elected chairman and secretary of the meeting. E. E. Mont- gomery of Philadelphia moved that the order of procedure should be "the consideration and advisability of organizing a continental association which has for its purpose the encouraging and maintaining of a higher standard of surgery." The motion received unanimous approval and the bylaws were again read article by article, and section by section. A. J. Ochsner moved that the bylaws be adopted as provisional, to be amended or substituted after careful and deliberate study and discussion. At the time of the Clinical Con- gress in Chicago the following November, permanent bylaws could be adopted. Ochsner's motion, which was seconded and approved, provided that every surgeon present should receive a printed copy of the provisional bylaws. After formal adjournment of the meeting of the corporation, Edward Martin declared the Board of Governors in session. A committee consisting of Truman W. Brophy of Chicago, Richard R. Smith of Grand Rapids, Michigan, and Henry P. Newman of San Diego was appointed by the chairman to nominate officers. Secretary Martin then read a resolution to provide for the Fellowship of the new organization. The methods used were not new. On a smaller scale, other medical organizations had been built around a nucleus of men who have chosen their fellow founders arbitrarily. They then established qualifications for membership. Criticisms against these methods remain as violent as ever. However, no other plan of creating a medical society has ever been suggested as practical, and no founders have ever escaped the charge of being selfish. The resolution provided that those surgeons who had been invited to become Founders of the corporation were declared eligible to become Fellows of the College of Surgons. If elected by the Board of Regents, they were to be designated as Founder Fellows without further formality. Other individuals, who limited their practice to surgery and its specialties and whose "sur- geonship" received the unquestioned approval of the Board of Regents, would be considered eligible for Fellowship without the formality of an examination. All members of the surgical 86 Fellowship of Surgeons societies which were included within the federation of societies constituting the Congress of American Physicians and Sur- geons would also be eligible candidates for Fellowship without examination. To effect the election of candidates for Fellowship by the Board of Regents, four classes of prospective Fellows were established. Class A consisted of the Founders. Class B consisted of members of the surgical societies included within the Con- gress of American Physicians and Surgeons. From each, 100 were to be nominated by the Surgical Section and the Section on Obstetrics, Gynecology and Abdominal Surgery of the Amer- ican Medical Association, the sections of general surgery and the surgical specialties of the Clinical Congress of Surgeons of North America, the American Association of Obstetricians and Gynecologists, the Canadian Medical Association, the Southern Surgical and Gynecological Association and the Western Sur- gical Association. Class C included surgeons of prominence who had been in the practice of surgery or its specialties for 10 years and who, in the opinion of the Committee on Credentials, were qualified for Fellowship without a formal examination. The fourth class included all those individuals who could not be placed in the first three categories. For these, the College would have to establish an examination or some other evidence of acceptable qualification. There was a final paragraph in the resolution which was ignored by the critics. This provided that the Board of Regents, through the Credentials Committee, should temporarily limit the admission of Fellows to those who could be fitted into Classes A, B and C until a standard of requirements could be formulated for the fourth group. These recommendations were to be submitted to the Board of Governors for approval at the time of the meeting to be held in Chicago the following November. The resolution was unanimously adopted in its entirety. From the audience, a slightly built man, whose face was adorned by white side whiskers, gained the attention of the chairman. Miles F. Porter, an 1878 graduate of the Medical Fellowship of Surgeons 87 College of Ohio in Cincinnati, lived in Fort Wayne, Indiana. He had been a general practitioner of medicine for 20 years, but in 1899 began to limit his practice to surgery. Porter had been an Instructor in Anatomy and a Professor of Surgery at the Fort Wayne College of Medicine, which later merged with the Medical College of Indiana and subsequently became the Indiana University School of Medicine. He had served as a Trustee of the American Medical Association for nine years. He was a mild, benign-appearing gentleman of the old school of doctors. Porter arose, he said, to inquire whether all the men invited to become Founder Fellows, and who had signified their willingness to do so, would become by virtue of those acts alone Fellows of the organization without any further formality. Edward Martin, the chairman, answered briefly, "They do not." He softened his brusque reply by asking if the speaker had any further questions. "Will Fellowship extend further than the mere ability to do surgical work?" asked Porter. Martin was now aware that this mild speaking, meticulously dressed older man might be concealing a bomb. It would be the responsibility of the Board of Regents to determine the quality and reputation of candidates for Fellowship. It was hoped, the chairman said, that the entire organization would have confidence in the discretion, wisdom and justice of the Board. Porter nailed down this statement, "That matter, then, is left to the Board of Regents?" "It is," was the answer. Porter then became specific. "As one who agreed to become a Founder, I want to say, I have no doubt that while I have quite as much confidence as anybody else in the Board of Re- gents, I think we are very likely to overlook what I consider a very vital thing. There are a great many men doing surgery in this country who can and do it well, yet who from a moral standpoint are unfit. I refer to fee-splitters. Such men should not become members of this body." 88 Fellowship of Surgeons The applause was thunderous. For the first time, one of the worst evils of the profession had been named publicly. It was to remain a question of bitter controversy—a principle upon which disagreement would bring about the formation of new societies and the passage of prohibitory state laws. It would incite action by component parts of the American Medical Asso- ciation, which would flaunt its Judicial Council and its Trus- tees, and it would constitute the basis for expulsion from membership and the cause for libel action. Miles Porter did have an explosive bomb in his possession. He set it off and for the remainder of his professional life remained quiet and firm in his convictions in the background away from the field of battle. The committee on nominations presented its recommendations for officers and members of the Board of Regents. Thus, J. M. T. Finney of Baltimore became the first President of the College of Surgeons. W. W. Chipman of Montreal and Rudolph Matas of New Orleans were elected the First and Second Vice- Presidents. Franklin Martin became the General Secretary and A. J. Ochsner, the Treasurer. Finney was modest in his acceptance speech and, as usual, forthright. He believed that the association should be dedicated to the good of the country at large. He recognized the objections to its formation even in the minds of some in the audience. He confessed that he had objections at first, but the more he thought about the plan, the more firmly convinced he became that it was needed. He urged them to unite and co-operate to eradicate the abuses which existed in the practice of surgery. Matas was the most eloquent and said what Franklin Martin wished he could express as well. "I believe I am voicing the sentiments of my southern colleagues when I say that those of us who are here tonight are ready to support this movement with all our good will and best energies because we believe that this organization will be a powerful and beneficent agency in the uplift of the practice of surgery. We intend to co-operate with our fellows throughout the country, because we have confidence in an organization which has for its aim the elevation of the standards of American surgery not only to the level of Fellowship of Surgeons 89 highest standards of the old world, but because it aims at realization of the highest of our own American ideals of at the surgeon should be. It should be clearly understood .t this movement is not calculated solely to benefit the sur- ms themselves, but through the elevation of their own stand- ls of efficiency and professional conduct, to benefit still more suffering public at large." Che first Board of Regents nominated by the committee and cted unanimously consisted of George E. Brewer of New rk, George E. Armstrong of Montreal, John B. Murphy of icago, Edward Martin of Philadelphia, Frederic J. Cotton Boston, Herbert A. Bruce of Toronto, Charles F. Stokes, ,geon General of the Navy, William D. Haggard of Nash- e, George W. Crile of Cleveland, Robert E. McKechnie of ncouver, Charles H. Mayo of Rochester and Harry M. Sher- n of San Francisco.5 Vhereas criticisms had already been expressed, eventually storm broke. In the May 1913 issue of the California State dical Journal, Philip Mills Jones had written an editorial ich was the opening gun.°

THE AMERICAN ROYAL COLLEGE OF SURGEONS—J.B.M. In this fair month of May, in the good city of Washington, is to be held a most remarkable meeting for the purpose of conferring upon American surgeons (query: who—or what—is a surgeon?) a collection of letters indicative of some tide, both title and string of letters being subjects for discussion. Martin (of Surgery, Gynecology and Obstetrics) and Murphy (of Mur- Rixford of San Francisco had shown his disinterest, or opposition, to the new ety. Since the west coast had to be represented and Los Angeles was still a ng growing community, Sherman of San Francisco was nominated. After his tion as a Regent, Sherman grasped Franklin Martin's hand and emotionally 1 that he owed him an apology. He admitted that, guided by misinformation misunderstanding, he had used his influence in opposition to the College. ally, he said he was either hypnotized or convinced by the remarkable presen- an of the plan of organization. He would take off his coat and help with all uis power. Through the years the convert became more zealous and energetic pis support of the College than other Regents who had been in the fold from beginning. California I. M., 11:5, 1913. 90 Fellowship of Surgeons phy's Clinics)—or should it be Murphy and Martin?—started the game and have skilfully encouraged the ambition to belong to something and decorate one's name with letters. How are the honored ones to be chosen? From the subscription lists of Mur- phy Clinics and Surgery, Gynecology and Obstetrics? Or shall the applicant merely have to attend and register at one of these huge surgical Martin-Murphy clinics? Or must the applicant have a real case of murphitis before he can be considered as a proper one to bear the mystic letters? May we suggest a few titles for this personally-conducted eruption into medical education? How would the "American Surgical Society" do? This could be used for the terminal-letter part quite nicely: "A.S.S., J.B.M." Or this one has been suggested: "American Royal Sur- gical Emporium, joined by me 1913," which would string out behind one's name quite nicely. Think of the ponderous psychological effect it will have upon one's patients to have one's cards and stationery printed with a whole lot of extra letters after his name. And we'll bet a suit of clothes to a tin-type of Murphy, that a lot of people will take this quite seriously! Jones followed with an editorial in the June issue of his journal? THE AMERICAN ROYAL SURGICAL EMPORIUM It was started, just as scheduled, in Washington last month; it is called, we believe, the "American College of Surgeons." Finney, of Johns Hopkins, is reported to be its president, and Matas, of New Orleans, its vice-president. And then there is a Board of Regents to cherish its early years and get its nice little feet directed in the right direction. And shortly the fun will begin. Who is a surgeon? What is a surgeon? "Why am I not entitled to belong to this holy organization; I once shook hands with Murphy and have removed ingrowing toe nails? Am I not a surgeon? Who shall say that I must be deprived of the glory of adding those mystic letters to my name? I was excluded from the original lists of the elect merely through jealousy; I am too good a surgeon; everybody is afraid of me and so they keep me out! Odds bodkins! Gads zooks!" And what in the world is the matter with all the "internists"? Are they asleep at the switch? Are they going to let the surgeons, Murphy-Martin di-

7 California J. M., 11:6, 1913. Fellowship of Surgeons 91 rected, put it all over them again? Are they not going to organize an American Royal College of Physicians? Is there to be no way in which a plain, ordinary, self-respecting physician can add a bunch of letters to his name and thus become a better doctor? It is pitifully scandalous to see such lack of energy; such inertia. Are there no great leaders among the physicians— the "internists," as they love to malign themselves? "Up and have at them!" Let us organize the "Internists' National Society Ab- solutely No One Excluded" and then John Jones may sign his name and have his cards printed "John Jones, M.D., I.N.S.A.N.E." And then let's all join the "Holy Rollers"! Evidently, Murphy was aware of the type of criticism and >position which would be directed at the new organization ith him as the whipping boy. He had refused the presidency the first Clinical Congress for that reason and on the train )ing to the Washington organization meeting again anticipated artin's wishes. Murphy warned Martin that if he had any ea of making him the President of the new organization, he ust abandon it immediately. It was Murphy who urged upon artin and the nominating committee the importance of elect- g John Finney, the first President. No one would attack Fin- y personally. It is of interest to speculate upon the attack which Jones ade upon Murphy. It is obvious in each editorial that Martin is unknown to him personally but was attacked by associa- >IL A man who urged in one editorial to speak well of one's ofessional colleagues always, became vituperative in his poor- concealed anger. Jones, for his own reasons, had given up tempts to practice medicine. A calm and more favorable editorial appeared in the May 13 issue of American Medicine. It was written by the editor io signed his name, H. Edwin Lewis, M.D. 8 THE AMERICAN COLLEGE OF SURGEONS was organized in Washington, D. C., May 5, "to elevate the standard of surgery, to provide a method of granting fellowships in the organization and to formulate a plan which will indicate to the ' Am. Med., 8:5, 1913. 92 Fellowship of Surgeons public and the profession that the surgeon possessing such a fellowship is especially qualified to practice surgery as a specialty." Its organization committee was authorized to decide what should be the minimum qualifications for a surgeon, to urge colleges to confer a special degree on their graduate physicians possessing these extra requirements, to urge new laws to limit the practice of surgery to those having such a degree, to publish the names of the elect and request members to add F.A.C.S. to their professional titles. We have repeatedly called attention to the necessity of a special license for those who profess the special abilities which come with years of preparation. We therefore welcome an organization the sole purpose of whose existence is to study ways and means of accomplishing this desirable end. Without having had an opportunity to study all of the purposes of this new movement—and the methods by which it is proposed to attain them—it is quite impossible to express any definite opinion as to what they may be expected to accomplish. The work undertaken is confronted by enormous difficulties and obstacles. Opposition from many sources may be confidently expected. Even the warmest friends of the project will probably admit the possibility of abuses creeping in and nullifying much of the laudable purposes of the organization. Time and time alone can show the practical utility of the plan that has been outlined, and demonstrate its fitness to bring about the reforms that the present day practice of surgery unquestionably requires. The most that can be said at the present moment is to commend most heartily the launching of a movement so urgently needed, so well organized, and with such splendid backing. Any plan or proposition that can claim the sponsorship that the American College of Surgeons can, deserves the calm, careful consideration of every medical man in the country. Every detail should be studied and weighed. Dispassionately, every prospect should be considered. Then, when a verdict or decision is reached concerning the plan, it will be fair and well founded with all due regard and consideration for its respected promul- gators. Although, at first blush, it was felt that the American College of Surgeons was a project of the American Medical Association, as events have unfolded it has become apparent that such is not Fellowship of Surgeons 93 the case. As a matter of fact, surprise has been growing steadily that up to now the Journal of the A.M.A., has not given its active support to this new organization. Since the American Medical Association has allied itself with every other movement for educational, legislative, sociologic and scientific reform, wonder is naturally excited that this plan to raise surgical standards and operative efficiency should be so completely ignored. In following issues we shall take up the consideration of the American College of Surgeons with the purpose of giving our readers an unprejudiced and comprehensive opinion of its objects, methods and prospects of accomplishing the praiseworthy purposes it assuredly has been created for. Announcement of the surgeons who are actively aiding this latest and most ambitious attempt to raise surgical standards not only points to the soundness of the organization, but wins for it a confidence in its underlying principles that will go far to insure its ultimate success. Before adjourning in Washington, the Regents had agreed to meet for the first time in Minneapolis during the meeting of the American Medical Association the week beginning June 16, 1913.9 On June 17, the meeting was called to order in the Minneapolis Club, and Harry M. Sherman of San Francisco was elected chairman for the session. Again, Martin read the bylaws section by section. A great deal of discussion arose over the use of the word "American" in the name of the organization. The charter for the corporation had been obtained in the name of the Ameri- can College of Surgeons. The use of the initials after one's name, whether it be F.A.C.S. (Fellow of the American College of Surgeons) or F.C.S.A. (Fellow of the College of Surgeons of America), thus allowing Canadian surgeons to use F.C.S.C. (Fellow of the College of Surgeons of Canada ), occupied a great deal of the evening. Jones' editorial had not been without effect upon their sensibilities. This weighty question was finally referred to the Credentials Committee, which already had the most difficult task of establishing the proper mechanism which ° Crile, Cotton, Haggard, Martin, Mayo, Murphy, Ochsner, Sherman and Stokes were present. 94 Fellowship of Surgeons would be as fair and honest as possible in choosing those qualified for membership. There was a discussion about the embarrassment of electing a Chairman to preside over the meetings of the Board of Re- gents, of which the President was a member. It was decided, nevertheless, to choose a Chairman at the beginning of each meeting. Martin called attention to the arbitrary classes of candidates established as a working basis for the beginning of the organization. He emphasized that within five years there would be no distinction. For the present, he believed that it facilitated the functions of the Credentials Committee. Here was the mechanism around which criticism arose, just as Jones had prophesied. Martin again found it necessary to instruct his fellow Regents. Even the men invited to Washington had to have their names submitted to the Credentials Committee and, if approved, were to be elected by the Board of Regents. They would have to qualify as would every other member, he stated quite emphatically. Murphy suggested that the phrase "for the convenience of organization purposes" be inserted to emphasize that after admission as Fellows there would be no classes. Edward Martin had agreed to serve as chairman of a committee to recommend the type of examination which might be given to properly trained and qualified recent graduates. However, he had been unable to complete a report in the month which had intervened between the two meetings. At the Washington meeting, Ochsner was named chairman of the Credentials Committee and had been given the privilege of naming the other members of his committee. He had chosen Doctors E. Wyllys Andrews, Dean Lewis, Charles Kahlke and C. S. Bacon. The obvious objection raised by Cotton that all of the members of the committee were from Chicago was discussed, but in the end the practicability of meetings in the face of an anticipated mountain of work prevailed. Ochsner was meticulously precise in carrying out his obligations as a committeeman and as Treasurer. He had prepared an Fellowship of Surgeons 95 application form, which obtained the quick approval of the Regents, and a letter which was to be sent to the applicants. On the back of each letter was a declaration which was to be signed and returned. The letter read: Dear Doctor: Your name has been referred to this committee for action and has been accepted. It has, however, seemed best for the sake of uniformity and for the purpose of making the American College of Surgeons a powerful instrument for good, to have each member fill and sign the enclosed form in order that it may be true that all members stand on the same ground. It has seemed to a few that the Founders should be exempt from this feature, but the strongest and best men in our profession to whom the question has been referred, have strongly urged this course of having on file these forms duly filled out, before the recommendation of this committee can be finally accepted. The Committee on Credentials solicits your criticism and suggestions. Very respectfully, THE COMMITTEE ON CREDENTIALS Martin had discussed this letter with Ochsner and told him it was "wishy-washy." It hoped for the applicant's approval and it did not convey the fact that the College would be adamant in its position upon fee-splitting. There were also other principles of importance which they should insist upon in order to elevate the practice of surgery. Ochsner's committee then wrote an explanatory preamble to a declaration, which each applicant was required to sign, and omitted the letter: At the meeting in Washington, when the American College of Surgeons was founded, the question was asked whether the College would positively exclude surgeons who were suspected of fee-splitting or paying commissions in any form whatsoever. The President declared that no one should be admitted who was suspected of being guilty of this pernicious practice. This declaration was received with universal and most enthusiastic applause. 96 Fellowship of Surgeons It does not seem possible that many men who would otherwise be eligible can belong to the class of fee-splitters, but the fact that the matter was so much emphasized has induced the Committee on Credentials to prepare the following positive declaration, which will be filed in connection with the credentials of each Fellow. If the College succeeds in eliminating this evil, the public will be enormously benefited. Very respectfully, COMMITTEE ON CREDENTIALS The declaration to be signed was directed solely toward the matter of splitting the patient's fee between the surgeon am the referring physician.

DECLARATION I hereby promise upon my honor as a gentleman that I will not, so long as I am a Fellow of the American College of Surgeons, practice division of fees in any form; neither by collecting fees for others referring patients to me, nor by permitting them to collect my fees for me; nor will I make joint fees with physicians or surgeons referring patients to me for operation or consultation; neither will I in any way, directly or indirectly, compensate any one referring patients to me; nor will I utilize any man as an assistant as a subterfuge for this purpose. The discussion was a vigorous one to which Martin listene( attentively. 1° Charles Mayo said, "They have a great scheme now of endangering the life of the patient by making then temporarily an assistant, taking a man with no training an making him a temporary assistant, so as to get around the fac of compensating with a fee." Murphy promptly suggested adding to the declaration th , phrase "nor utilize any man as an assistant as a subterfuge fo this purpose." Haggard thought that it was "pretty strong. Th physicians cannot come in the front door." Murphy replied, without recognition from the Chairman

10 Stenographic report, Minutes of the Board of Regents, Minneapolis, June 1 1913. Fellowship of Surgeons 97 "Yes, he can come in, come in the front door and out the back, but not get part of the compensation the surgeon got for the operation." On and on they talked, without order, about "signing before a notary," the "honor of gentlemen," "offending prospective applicants' feelings" and always about the "viciousness of fee- splitting." Miles Porter had only brought the words out on the floor of the meeting; they all had strong feelings about the practice. Finally, Martin was able to get the chairman's attention and the floor. He introduced his remarks by saying, "I approve of every line of that declaration, but this organization, if those who were instrumental in organizing it have a right to say anything, was organized first for the scientific advancement of surgery in every line of work in connection with surgery." Martin thought it unwise to particularize in a single declaration against fee-splitting. "There are a number of things that are as bad as splitting fees. . . . If we are going to have an oath, we ought to first make the point that this association is for the elevation of surgery. . . . It would be better to have some kind of an oath that would make him swear, if he is going to swear, that he will fit himself to practice surgery." Mayo said it should be a pleasure for Cushing, Halsted, Mur- phy and every other prominent surgeon to sign a declaration that he was not a fee-splitter. The usually quiet, retiring Doctor Charlie was uninhibited as he stated, "It is terrible in Iowa; really you have got to spin that Iowa crowd down so close that you will hardly have a qualified crowd to go into this association. . . . I do not care a snap. If this thing is not going to start straight, I do not want to be in it." Crile, Murphy and the others joined the fray. Soon the question at issue appeared to be one of being for or against fee- splitting. Carried away by emotions and the unrestrained opportunities to talk, it is not uncommon for a group of individuals to leave the original point of discussion and put words into the mouth of their opponent. Martin sat by patiently until they had exhausted their emo- 98 Fellowship of Surgeons tions and their vocabularies. Then he spoke. "Mr. Chairman, may I make myself clearer? I approve of this oath, but I do not want it alone. To have it go to the public that this is the only problem we have and have established this organization to combat is wrong. I would move that this matter of the oath be referred to the Committee on Credentials with the idea of working out something that will be dignified and not magnify one immoral practice of our profession, while it ignores entirely all of the things we are established for. I have just written out something here. It is imperfect, and it must be revised, but it covers some of these points." Cotton thought Martin's version a "dignified credo"; Murphy said it was "splendid and beautiful." Crile wanted "something drastic." Ochsner was satisfied and Mayo was silent. Mayo moved that the oath, as read, be referred to the Cre- dentials Committee together with the declaration against fee- splitting read by Ochsner so they might resolve the question. This should have put an end to the discussion for the evening, which was getting late, but the Chairman, Sherman of San Francisco, felt moved to make his opinions known. As his introduction, he compared those who went to the altar and promised to be true to one woman, and then broke that sacred vow, with those who would sign a declaration against fee-splitting with no intention of keeping it. They were small in number compared to the righteous members of the community and the medical profession. Recognizing that the entire evil existed because of the desire of men to get money and that no one could ever eliminate that desire to get money, he said it might be possible to arrange that there should be an open acknowledgment and an agreed upon method by which physicians and surgeons jointly engaged on any specific case should be compensated. He said that lawyers and architects had such definite relations based upon a percentage relationship. Sherman went on in detail until Mayo interrupted him by

° See Appendix, Chapter 3:4. Fellowship of Surgeons 99 saying that it would take too much time to discuss the com- plexities of his proposal with each local medical society in the United States. "You will never organize if you are going to make it strong and at the same time agreeable," said Doctor Charlie. Murphy now evidently sensed that Sherman was attempting to delay action. Murphy's recorded words did not always make sentences and he was repetitious. "I do not think it is incum- bent on this body to establish a price for a physician or surgeon, or a percentage price. I think the physician and surgeon must be each left free to make his own fee, and that I am not going to carry any part of the burden of making a fee for the physician who sends me the case, and I am not going to ask him to carry any part of the burden of making a fee for me. One of my very earliest big fees was a $2,500 fee for a diagnosis, and I got the money and the physician that has not got the conviction of the value of his own prices must go on taking what he is getting, and I am not going to be the means of training him as to what he should get, or bearing his burden to get it. That is the proposition. It is not a matter of lifting him up; he does not need to be lifted up. If he is not man enough to lift himself up and come up and insist on his own value, that is his proposition, but he is not going to split it and carry it with me. That has always been my position, it is my position now. "Dr. Billings does not expect any man in Chicago to carry any portion of his fee. I recall a case where Billings came in in consultation, agreed that an operation should be performed; he stood by with his hands folded when he was not smoking a cigarette, and he charged a thousand dollars for looking at me doing it. That is the stuff. And when the everyday doctor gets down to say here, this is my price, this is my value, that is all right. But, where he wants me to pilfer, directly or indirectly, or even shadily for him, I am not going to be a party to it, nor a member of an organization that recognizes him either directly or indirectly, if I know it." Sherman took exception by saying that he did not believe 100 Fellowship of Surgeons that what Murphy had said applied to what he had proposed. Martin reminded the heated debators that he had made a motion. The Chairman was temporarily at a loss to know what the motion was. Mayo then moved that the declaration against fee-splitting be made a strong statement and incorporated in Martin's oath and that the Credentials Committee be empowered to prepare such an oath to be sent to applicants without further delay. Ochsner then proposed the establishment of credentials committees in each state and province to deal with future applications but emphasized that these committees could be established only by having the Regents appoint three members and asking those men to elect two others. The name of each applicant for membership in Class A (the Founders' group), in Class B and in Class C was read state by state and province by province. Even though the Credentials Committee did not have all of the information it needed for each candidate, Ochs- ner requested that the Regents give their approval to the final lists which would be prepared by his committee. Otherwise, he pointed out there would be no initiates for the first annual convocation of the College scheduled for the fall in Chicago. Ochsner's ministerial air and appearance swung the balance in favor of his suggestion. However, the Regents were em- phatic in telling him that his committee should make no mistakes in the admission of men to Fellowship "who were not straight." They also pointed out that they would have the final vote even though it occurred just the day before the initiation of the candidates. It had been a long night of debate and exchange of ideas among opinionated men. In his own way, each had learned more about the individuals with whom he was now associated in this new venture and had professed his faith and loyalty. Martin wished that the full membership of the Board had been in attendance. They adjourned to meet on October 9, 1913, in Chicago, a full month before the meeting of the fourth Clinical Congress during which the first convocation of the American College of Surgeons would occur. Fellowship of Surgeons 101 Philip Mills Jones continued his tirades each month in the California State Journal of Medicine.11 . . . We learn that there is to be a Board of Governors consisting of the first five hundred to be invited to attend the emporium by the original Murphy-Martin committee; they are to be known also as Founders of the College; all other ordinary mortals are to be merely Fellows of the College; thus you see the first bunch get two nice titles right at the jump off. . . . Class "A" one would suppose would indicate Fellows especially handy with the appendix; Class "B" should point out to the incontinent or the suppressed a Fellow who is keen on the bladder; Class "C" might be used to designate those of the Fellows who are highly commercial and notorious fee-splitters; of course, it is obvious that the man with an ingrowing toe nail will have to pick a Fellow from Class "D," or one who does diverse odd jobs.

Walter M. Brickner, editor of the American Journal of Surgery was more analytical, though equally opposed in his critical editorial comments.12 Quoting from the invitations of the Or- ganization Committee, he offered his comments: . . . to the extent that it will merely indicate to the profession and to the laity those who are recognized as experienced, such a plan, fairly and liberally pursued, will serve a useful purpose and deserves, it seems to us, to be commended. But, we fear, the American College of Surgeons, even in its present tentative and somewhat nebulous form, seriously proposes to go much further than this. . . . the establishment of a standing committee on legislation, the provision for huge financial assets, and the personal statements to us of members of the established Board of Governors and Board of Regents, leave no doubt in our mind that the College of Surgeons does seriously and certainly, however vaguely, intend to seek laws establishing what constitutes surgery and who may and who may not be "allowed" to practice it. . . . Nevertheless the rank and file of general practitioners 11 California J. M., 11:7, 1913. 12 Am. J. Surg., 27:6, 1913. 102 Fellowship of Surgeons of medicine and surgery and of aspiring specialists ( and very many of both of these classes do excellent surgical work) will bitterly resent any legislative disturbances that threaten to rob their licenses of the right to practice any branch of medicine to which their tastes, their talents and their opportunities may attract them, or the necessities of their environment may develop them. . . . We would not condemn any definite plan of the College of Surgeons before it is uttered, but we would urge the College to proceed in the consideration of legislative restrictions very cautiously, to make haste very slowly. Dr. Brickner had great difficulty, it appears, in riding his horse without sawing himself into two pieces. Finally, he said he could not refrain from commenting upon what was to be done with all the money which would be collected from the initial fee of $25.00 and the annual dues of $5.00. "Apparently," he ended his editorial, "the annual tax merely continues an active membership that conveys no other privilege than that of voting once a year for the Board of Governors who are, in turn, to vote for the Board of Regents." Neither Brickner nor Jones wrote from firsthand knowledge of the plans proposed, neither was a practicing surgeon, and neither made any effort to search for the facts and report them. An editorial in the New York Medical Journal in July 1913 rose to the defense of the general practitioner in the most un- emotional statement which had yet appeared." .. Few of our readers will be inclined to deny that both the profession and the public need some means by which to determine whether a would be practitioner in a surgical specialty deserves their support or not; so we welcome the college as an attempt to fill this need. . . . The fact that it seems to have been taken bodily from the custom of our British brethren should not weigh for or against it, but we believe that if the college is to succeed it must win the support and the confidence of the profession at large, which seems to be noncommittal at present. To do this it must make clear the benefits to be derived 18 N. York M. J., 98:2, 1913. Fellowship of Surgeons 103 by the general practitioner from the organization. We do not believe that the founders have any intention to create a monopoly of surgical practice, yet it is not difficult to read such a purpose into the report of the proceedings at their meeting, which contains nothing definitely protective of the rights of the general practitioner. A very serious objection to the plan presented is that it affords an opportunity for a certain set of men to brand as incompetent, by refusing them admission, others as competent as themselves. We would not be understood to intimate that the gentlemen who are at present entrusted with the passing on the merits of candidates for admission to the college would do this knowingly or willfully, but they have the power to do so, and history tells us that such power has been abused in the past. . . . It is another matter that these gentlemen cannot be personally acquainted with the merits or demerits of all candidates, and may be misled; so far as this is concerned mistakes are to be expected in every human undertaking. The New York Times of August 10 made headlines out of the editorial.

CLIQUES COULD WITHHOLD THE RIGHTS F.C.S. USE OF PERSONAL PIQUE MIGHT MISLEAD PUBLIC ORGANIZATION OF NEW COLLEGE EVOKES ADVERSE CRITICISM FROM MEDICAL JOURNAL - FEARS A MONOPOLY Support came from an unexpected source, an editorial in the. Journal of the Tennessee State Medical Association of June 1913." After quoting Jones' editorial comment and branding it a vicious attack, the editorial continued: . . . The above expression neither does justice to the capable editor of the California journal nor to the men, Doctors Murphy and Martin, whom he attacks. . . . It is exceedingly unbecom- ing for the journal to refer to Dr. Murphy as Murphy of Mur- phy's Clinics, or Martin as Martin of S.G.&O. It is quite obvious that these gentlemen need no defense from such slander, for they have made Murphy's Clinics and S.G.&0. and the publications are merely reflections of their greatness.

14 I. Tennessee M. Ass., 6:6, 1913. 104 Fellowship of Surgeons On the first page of the California Journal there appears a conspicuous half-page advertisement of "Murphy's Famous Clinics." It would seem that there is not the most perfect harmony existing between the editorial and business offices. Or, must it be inferred that the editor deliberately sells one portion of his publication to advance the interests of a man for whom editorially he expressed nothing but contempt? Consistency? Square dealing? Without editorial comment, The Journal of the American Med- ical Assocation reported the facts concerning the plan of organization and the classes created temporarily for the screening of candidates for Fellowship. Officially, the American Medical Association had not decided whether or not the new surgical association would be successful in organizing. There would be time enough to decide whether or not it constituted a threat to the Association which supposedly spoke for the medical profession. The imaginary threat of the American Surgical Asso- ciation had quickly disappeared as its members concerned themselves with the scientific and professional aspects of surgery and apparently were uninterested in political machinations. Other state medical society publications expressed their opinions, the majority of them in support of the reform venture. The Journal of the Michigan State Medical Society urged the hearty and earnest support of the medical profession and added, "If it holds itself aloof and free from medical politics and politicians, it is destined to become the most potent factor in directing and establishing the standards and requirements for all who desire to devote their life to surgery." It was wise, said the Interstate Medical Journal, to make the organization inclusive rather than exclusive but it warned that tradition is established at a slow pace. 16 The Journal of the Iowa State Medical Society understood the purpose of the organization to be to bring together those surgeons who have a common interest in maintaining high standards and of eliminating certain commercial methods,

15 1. Michigan M. Soc., 12:6, 1913. 16 Imerstate M. J., 20:6, 1913. Fellowship of Surgeons 105 which if continued, bid fair to bring permanent discredit upon the medical profession." Undoubtedly, the editor pointed out, mistakes would be made in selecting the names for the first group of Fellows and those who failed of election would be the most willing critics. It had become apparent, said the editorial, that most of the criticism was wide of the mark and it was absolutely wrong to say that the purposes of the College were to create an aristocracy in surgery "unless right doing is a badge of aristocracy." In view of Mayo's remarks about the fee-splitters in the State of Iowa, this editorial gave hope that the profession in that state was not entirely lost to commercialism. Martin was far more sensitive to the personally directed criticisms than was Murphy. Martin was disturbed by the injustice of Jones' attacks upon them, without investigating the facts or giving them an opportunity to discuss the purposes of the Col- lege with him. Murphy always listened to his protests sympathetically, but brushed aside Jones and his kind as being unworthy of his attention. In answer to Martin's queries, Murphy finally convinced him that there was no such thing as impersonal criticism. Such criticism would be like an impersonal fist fight or an impersonal marriage, he said, and just about as successful. Therefore, one had to measure the weight of the personality of the critic. Martin knew, however, that not all of the Regents were so judicial. The Seventeenth International Medical Congress, under the presidency of Sir William Osler, was to be held in London the first part of August 1913. George Crile, Harvey Cushing, Wil- liam Mayo and John B. Murphy were to receive the Honorary Fellowship of the Royal College of Surgeons of England. Martin was convinced that an air of academic dignity should become a part of the new College and be one of the first steps in the creation of a tradition. He could learn something of the traditional procedures if he could attend the ceremony of the Royal College. Martin had broached the subject of an academic gown and hood to be worn at the first convocation of

17 1. Iowa M. Soc., 3:8,1913. 106 Fellowship of Surgeons the College but had been voted down by his fellow Regents. Charges of looking utterly ridiculous, creating an undemocratic atmosphere and the fear of lampooning criticism came only from his colleagues who had not attended college preliminary to their entrance into medical school. He hoped that perhaps Murphy and Crile would have to wear the gown of the Royal College to receive their honors. Through the efforts of Mrs. Murphy, who was bold enough to ask, Franklin and Isa- belle Martin and those wives of the four Americans who were present, were invited to witness the ceremony on the afternoon of August 6, 1913. Primarily, Franklin Martin was determined to get an acceptance from Sir Rickman Godlee, President of the Royal College of Surgeons and a nephew of Lord Lister, to deliver the dedi- catory address at the first convocation. The four American recipients of Honorary Fellowships had prepared Sir Rickman for the invitation and found him sympathetic, but it was necessary for him to obtain the approval of the Council of the Royal College. Franklin and Isabelle Martin returned to Chicago with God- lee's acceptance to be present in November with his wife, the design of an academic gown prepared by the firm of Ede and Ravenscroft, official gownmakers to His Majesty, the King, and the memories of a charming weekend with the Godlees. Fur- thermore, they were completely saturated with the atmosphere and traditions of the famous Royal College upon which Martin had built his dreams of the American College of Surgeons. As Martin knew, several of the Regents were deeply concerned about the criticisms of the College, particularly the ones directed toward the methods of choosing Fellows and the fee to be charged for Fellowship. The entire discussion at the Regents' meeting in Chicago held in the Union League Club on October 9, 1913, concerned these provisions in the constitution. They had designated 15 societies, believed to be representative of the best in surgery, from which Governors of the College could be chosen. Applications from three members of the American Asso- ciation of Obstetricians and Gynecologists from Baltimore were Fellowship of Surgeons 107 not acted upon favorably by the Central Credentials Committee after they had received an unfavorable report from the local credentials committee. Immediately, charges of favoritism, un- fairness, personal jealousy and political expediency were directed at President Finney. This conscientious man was sensitive to criticism, idealistic in his attitudes and unyielding in his principles. Frederic Cotton was the chairman of a committee to study and suggest revisions of the constitution and bylaws. Ochsner and his Credentials Committee from Chicago had been working two nights a week pouring over in detail, applicant by applicant, the qualifications of surgeons who were seeking Fel- lowship. Already, Ochsner said, there were over 2,000 applications to be considered by his committee. It was their rule to consider each applicant individually and to give careful consideration to the opinions of the local surgeons who had been qualified as Founder Fellows. If any one member of the committee was not satisfied, the application was tabled until more information was available. Discussion at the Chicago meeting of the Board of Regents centered about the standards and quality of members in the American Association of Obstetricians and Gynecologists. This society had developed, said George Crile, because the Ameri- can Gynecological Society had discriminated against excellent and strong men in choosing their members. Murphy said that he was a member of the former group and that the meetings had been good. As he understood it, the Regents were not electing any particular society to Fellowship but were, instead, choosing individuals qualified as surgeons. Finney argued that to take a member from a surgical society into Fellowship was in effect to sponsor the aims and ideals of that society. It was this characteristic of Finney to extend his philosophical principles beyond the level of practicality which had the beneficial effect of slowing down precipitate action. It always required a considerable amount of time to convince the Presbyterian minister's son that a change in his opinion would be within the framework of his ethical and moral prin- 108 Fellowship of Surgeons ciples. It was also somewhat frustrating to his quicker minded and more practical colleagues. The standards of admission to membership in the Western Surgical Association also came into the discussion. Finney wished to be reassured that dermatologists were not to be considered for Fellowship, and there was some doubt expressed later among the other Regents that he was serious. Ochsner assured him that they were not eligible "unless they were surgeons." The plan to reduce the original number of Governors from 300 to 150 was rehashed. The Army and Navy medical services were given the opportunity to nominate two members of the Board of Governors from each service. Each Regent was conscientiously examining the criteria which he would individually apply to the candidates to be presented for Fellowship. Ochsner gave a detailed report of the bookkeeping system to be used. It was patterned after that of the Standard Oil Com- pany and was installed by one of his patients, an employee of that company. A system of vouchers and counter checks, he assured them, would make it impossible for funds to be diverted from their appropriated use. Those who questioned the use of moneys to be obtained from the entrance fee and annual dues had no imagination or vision as to administrative costs or the educational purposes to which the money should be put. After a debate which was highlighted by the obvious inability of several of the Regents to do simple exercises in arithmetic, it was decided that an applicant could pay $25.00 upon being admitted to Fellowship and $5.00 annual dues for five years. Thereby, he would become a life member. If he wished, he could pay $50.00 at the time of initiation and become a life member without paying dues. It appears that the word "dues" was a stumbling block. What if the individual refused to pay dues? Could his degree, or Fellowship, be revoked? Once he received his Fellowship and used the letters F.A.C.S. after his name, said Finney, the degree could not be taken away. Ochs- ner said that his name could be taken out of the "blue book," the proposed directory of qualified surgeons. Martin reminded the Regents that there were other more important points for their consideration. Anticipating what should Fellowship of Surgeons 109 be done if an individual did not pay his dues could be left for the smaller committee on the bylaws to solve and submit to them for approval or disapproval. They should discuss fully, he reminded them, the qualifications of surgeons who were applying for Fellowship. The Central Credentials Committee could learn their views and formulate procedures which would remove as completely as possible any personal prejudices in the choice of candidates. Martin suggested that Ochsner cite examples of the difficulties which the Committee had faced. A man, who had practiced in a small community for 43 years and who was a "first class" doctor, had submitted his application supported by recommendations from the local committee on credentials. He had not served an internship and had learned his surgery by operating upon patients. He was not a teacher and had no hospital staff appointment. In fact, there was no hospital within miles of his town. He was a fine citizen, beloved by his fellow townsmen and respected by the doctors in his state. He used fine judgment, it appeared, by not operating when he thought the procedure was too much for his talents. Ochsner tried to present the case fairly but almost immediately was jockeyed into the unsought position of defender by the vehemence of his fellow Regents. Edward Martin said that it was impossible to make the College too small, but it was easy to make it too large. The value it would exert upon the elevation of the standards of surgery was in direct proportion to the care used in the selection of members. Crile and Cotton wanted to adhere strictly to the rules. Ochsner reminded them that they had forgotten there were no set rules as yet and that was the purpose of the discussion. Finney was anxious that the confidence of the profession in the new College be established quickly and the way to do it was to make wise selections. He was hardly willing to concede that a mistake in judging applicants' qualifications might be a human frailty. Murphy's motion that the Committee on Credentials be supported in "rejecting all general practitioners doing surgery who have not by previous preparation qualified themselves by adequate training in surgery" was unanimously passed. Would an applicant have to limit all of his practice to surgery? 110 Fellowship of Surgeons This appeared to be a requirement impossible to enforce. At least, they agreed that 30 to 40 per cent of the applicant's practice should be limited to surgery. In the future, as opportunities for training improved and became more abundant, this percentage should be raised higher and higher. Again, the question of Class A, B, C and D candidates came up for discussion. Martin pointed out that his use of the word "class" had been a mistake. More properly, he should have said "group." This word did not connote separating the Fellows into classes when they had been admitted. Class A, however, was closed when the meeting in Washington was adjourned. Those men were the Founder members, if they wished to apply. Mar- tin emphasized that the Regents had the right to deny any one, or all of them, membership. Classes B and C should be closed within a year. Matas wanted his colleagues to define the qualifications for applicants in Class C more specifically. These were individuals who had been engaged in the practice of surgery for five years but had never had any special training in surgery. He and his committee in Louisiana were having a difficult time in weeding out properly qualified men from a flood of applications. What exactly should constitute training in surgery? Matas said that the provisions for choosing Fellows from applicants placed in Class C did not say they should be engaged exclusively in the practice of surgery for five years, as perhaps it should. There were, he said, a large number of men associated with medical schools as instructors in surgery and assistants in surgical clinics, men who were already identified as teachers of surgery. "What did prominence in surgery mean?" he asked. One might be prominent in his locality and yet not be a prominent surgeon technically speaking. These younger men would become valuable members of the College and must be encouraged to apply for Fellowship, but the Regents should establish definite criteria for the guidance of local credentials committees. Finney was unwilling to write down the definition of training in surgery. Their convictions must evolve after repeated dis- Fellowship of Surgeons 111 cussions of the many problems which would arise from time to time. In the meantime, the state and the central credentials committees must assume the responsibility of exercising judgment. This was the first use of the term "state credentials committee." By usage and the custom of accepting the judgments of the local committee as correct until proven otherwise, a long step would be taken in establishing the medical profession's confidence in the acts of the governing body. Edward Martin's committee was still struggling with a report which would recommend to the Regents a method of determining the qualifications of applicants grouped in Class D. His committee was in favor of an absolute rule which would require an examination. The committee hoped that such an examination could be given by the Canadian and United States governments. This would be the first step, he believed, in centralizing examinations for licensure throughout both countries instead of having a multitude of state board licensing examinations. This report was a heavy, radical dose for Edward Martin's colleagues to swallow. Quickly, they pointed out that the details were not worked out. He agreed that it was a tentative plan at the moment. They happily, though unfortunately, tabled the report for reconsideration at a future meeting. Again, a discussion of the question of the ethical and moral fitness of candidates for Fellowship was precipitated by Ochs- ner's proposal to change a few words in the oath which the applicants were required to sign. Applicants had written to the Central Credentials Committee saying that to sign the oath as written would work a hardship upon them. They would agree not to split the patient's fee. However, the patient often paid either the physician or the surgeon the entire fee for both of their services, received a receipt for the amount and expected the recipient to forward the proper amount to the second physician. The thoughts of the Regents had become crystallized about fee-splitting, joint bills and all of the methods of "crawling out," as they put it. The declaration, or oath, against fee-splitting was made even stronger by the revision which Ochsner suggested and was adopted quickly. 112 Fellowship of Surgeons Dr. Joseph E. Blake of New York had received newspaper publicity and considerable notoriety because of domestic difficulties which had resulted in divorce proceedings. He had been accused of infidelity. Blake was an outstanding surgeon in New York and had been included in the group of Founder Fellows. He was a member of the American Surgical Association. Chairman Finney asked if he were a member of the College, and Ochsner replied, "As much so as any member who has been passed by the Credentials Committee and whose name must be approved by this Board of Regents." Finney objected to the inclusion of Blake's name, stating that to him "evidence of character should stand for as much as attainment." It developed quickly that the consideration of the name of Roswell Park of Buffalo also had been postponed by the Creden- tials Committee. Franklin Martin suggested that these decisions should be delayed until the Central Credentials Committee had the opportunity to gather more facts. The Regent from New York, George Brewer, should be asked to assist the committee and should be present when Dr. Blake's and Dr. Park's names came before the Regents for approval. Martin brought their attention back to the qualifications for Class D applicants. He said, "Mr. Chairman, may I say a word about Ned Martin's plan? If I have any idea of what we are seeking in the end, I believe he has got the plan that will bring about the thing we must aim at. Of course, we are not to be an ornamental body; we must do things. Let us make the standard for the young men just as high as it can be made and be reasonable; and through the committee's work, the postgraduate departments of Harvard, Johns Hopkins and Rush ( encourage) them to bring their standards up and furnish what our young men have got to have. We must boost this idea all along the line. That plan can be worked out magnificently and would give us great prestige if we could have the government officials at the head of the examining boards of each country." Secretary Martin reported that Dr. Finney, Dr. Cotton and he had decided upon the Gold Room of the Congress Hotel in Fellowship of Surgeons 113 Chicago as the proper place for the first convocation of the College to be held in November 1913. As Martin spoke, young men, wearing the sample gowns he had ordered, paraded around the room silently. The dark blue academic gown trimmed in bright red was simple and subdued. The fears of those who anticipated a brilliant plumage were allayed. The final action taken was to instruct the Secretary to offer Honorary Fellowships to Sir Rickman Godlee, Robert F. Weir of New York, J. Collins Warren of Boston, William S. Halsted of Baltimore and W. W. Keen of Philadelphia. The Board of Re- gents was to meet again during the week of the fourth Clinical Congress and before the Thursday evening convocation.

Philip Mills Jones had continued each month to attack the "college of surgeons," as he now referred to the organization. He accused Edward and Franklin Martin of railroading the constitution and bylaws through the Washington meeting. Again, Jones was guilty of not being a good reporter.18 Thus, the "Great College" was born! Now the question arises, what good will it do? Every one licensed to practice medicine is or may be a surgeon; he has as much right to do surgery as the biggest, and a good many of him is doing it and is going to continue. The only people who seem to be threatened with an examination are those who may come along hereafter and they do not need it so much as some of the founders! It is a personal and proprietary eruption into the domain of medical education and comes just at a time when proprietary medical schools are decreasing. . . . It has yet to be shown wherein the College can do or proposes to do or has planned to do the slightest good except for permitting the use of some letters after one's name! Other editors, more impersonal and analytical in their attitude and who were lukewarm in the beginning, had learned more about the aims and objectives of the College. In October 1913, American Medicine again commented editorially."

" California J. M., 11:8, 1913. " Am. Med., 8:10, 1913. 114 Fellowship of Surgeons WHO SHALL BE F.C.S.? — The fear expressed in certain timid quarters that some restriction may be imposed on the reckless surgery of men whose skill and diagnostic ability are looked upon askance by their confreres, by the care to be experienced in conferring the new honorary title of Fellow of the College of Surgeons, is, we hope, to be thoroughly justified. That the honor will be refused to any surgeon really worthy of it is in the highest degree improbable, and, on the other hand, that it will be carelessly conferred upon incompetent applicants is hardly more likely. We have every confidence in the original holders of the honor; and whenever it is accorded in the future, whether by invitation or on application by a candidate, there need be no fear of carelessness or favoritism. The time is ripe for action of this kind; there will be no danger, as there might have been, say, twenty years ago, of men acquiring the coveted distinction solely on account of great technical skill, while their personal characters left much to be desired. In times past we have produced, in spite of unavoidable handicaps, a remarkably high average of surgical skill and personal endow- ments; with our present advantages, however, we are beginning to lead the world in the surgical branch of medical science, and in order that perfect confidence may be felt in the proper men, it is well that the few black sheep be indicated, even if in only a negative manner. Once more, the California State Journal of Medicine attacked 20 The personal diatribes against Franklin Martin and Murphy stopped, influenced without doubt by the fact that Harry Sherman of San Francisco had become a Regent and had tried to present the facts to the "catalyst of Pacific Coast medicine." Jones questioned editorially the desirability of the Clin- ical Congresses. Were they altogether an unmixed blessing? . . . Is there not a considerable element of danger? Many very able and skillful surgeons will perform remarkably deli- cate operations in a manner and with an ease that are totally deceptive; it looks very easy to do some particular thing when one watches an expert with apparently no effort and with a rapidity that still further adds to the illusion, perform his operation. Will not many a man who lacks ability to handle his fingers,

20 California J. M., 11:10, 1913. Fellowship of Surgeons 115 to say nothing of the mechanical brain behind them, go home and try to do that same piece of work that looked so easy when he saw it done by the expert at the "congress"? There is a tremendous gap between the ability of the expert and that of the average man and we must remember that in our work it is not merely some material and time wasted in a failure — it is life or health, and these cannot be lightly considered. Jones had screamed that any licensed doctor had the right to perform surgical operations. Now he was admitting that some surgeons were better than others but that no attempts should be made to elevate and educate so that there would be less risk to the life and health of all patients. Jones was at his best when he wrote libelous personal pieces in which he did not bother to learn some of the facts. They were inflamma- tory and helped to set off a chain of explosive actions and es- says. When he began to center his fire on specific aims of the College, his editorials sputtered and fizzed. The fourth Clinical Congress was in session from the 10th to the 14th of November 1913. The committee on arrangements was an active one consisting of young surgeons in Chi- cago under the leadership of E. Wyllys Andrews. Daily bulletins of the program of clinics and presentations were issued. A group of surgeons from abroad was headed by the distinguished president of the Royal College of Surgeons who was to deliver the inaugural address of the new American College of Sur- geons. It was reported that 2,591 men had registered at the New York meeting the previous year, and the auditors verified a loss of $46.50 for that meeting. The headquarters in the La Salle Hotel was the scene of confusion and turmoil as 3,989 doctors registered and received tickets which would admit them to the clinics of their choice. More than 2,000 of them had sent in their applications for Fel- lowship, and each was anxious to know if he had been accepted and would be initiated at the first convocation to be held on Thursday evening, November 14. Evening meetings preceded by dinners and other social events centered about the visiting foreign surgeons. 116 Fellowship of Surgeons On November 11, Dr. Ernest A. Codman of Boston gave the report of his committee which had been appointed by Ed- ward Martin to study the elevation of the standards of hospitals. This was a matter in which Edward Martin was greatly interested, and he had chosen the right man to head the committee. Codman had presented a paper before the Philadelphia County Medical Society on May 14, 1913, stating that for many years he had collected the annual reports of many hospitals in the United States. He had done so because he believed that the main product of a hospital was the patient who had been treated there. The efficiency of a hospital could be determined only by a study of the end results of such treatment. Codman said that the skill of a hospital's staff of doctors could be judged only by the "common sense notion that every hospital should follow every patient it treats, long enough to determine whether or not the treatment has been successful and then to inquire, if not, why not?" In this report, the committee suggested a type of end result record system and made three suggestions, one of which included the intimation that the Carnegie Foundation would support financially the enormous task of investigations, reports and policing that would be necessary to make a reform program effective.21 1. That this Congress give the stamp of its approval to an investigation of hospitals by the Carnegie Foundation and em- power its representatives to urge the foundation not to limit its inquiries, purely to the bearings on medical education but to classify hospitals according to their actual efficiency. 2. That each of us do what he can to induce the trustees of his own hospital to organize a followup system for all patients treated. 3. That each of us do what he can to induce the fellow members of his staff to appoint efficiency committees who may look into present conditions in his own hospital in order that we may, as far as possible, do our own house cleaning.

21 Report of the Committee on Standardization of Hospitals. Surg. Gyn. Obst., 18:7, 1914. Fellowship of Surgeons 117 Although committees had been appointed for similar purposes by the American Medical Association, American Hospital Association and local societies in Pennsylvania and Massachu- setts, no action had been instituted. Codman had written the report with the unanimous approval of his committee. He had been interested in the records kept upon patients since his intern days at the Massachusetts General Hospital when he and Harvey Cushing designed and used a chart upon which could be recorded the pulse, blood pressure and respirations of the patient during the administration of an anesthetic and performance of the operation. Obviously, Codman had written, there are many standards by which hospitals can be compared: architecture, cleanliness, kindness to patients, nursing care, medical education, per capita cost, the number of patients treated annually, the success in practice of the physicians and surgeons on its staff, the quality of the scientific papers produced by these doctors, the mo- dernity of its laboratories, or the famous contributions which some member of the staff made a hundred years ago. All of these would not mean necessarily that the patient would be freed from the symptoms for which he sought relief. Codman spared no one connected with hospitals. Further personal investigation of a number of the best institutions in the country developed the astounding fact that no effort is made to trace the patient beyond the gate of the hospital except such investigation as is individually made by members of the staff for their own interest. A patient might be operated upon, leave the hospital with the wound healed, and yet no effort be made to record the result of the operation. In other words, we have the paradox that neither the hospital trustees, the physician, nor surgeon, nor administrator consider it their business to make sure that the result to the patient is good. In moving unanimous acceptance of the report, Dr. Thomas B. Walker of St. John, New Brunswick, requested that the report be sent to the American Medical Association and to the Canadian Medical Association with the suggestion that it be 118 Fellowship of Surgeons considered seriously by those two large medical societies. Dr. E. Payne Palmer, who was working hard to establish proper hospital facilities in Phoenix, Arizona, seconded the motion and added the amendment that the report be sent to every hospital in North America. Thus started one of the greatest contributions to the care of the sick which removed the fear of the hospital and "the black bottle" from the minds of ill patients. During the meeting in New York the previous year, the Clin- ical Congress of Surgeons gave one evening to the discussion of cancer of the uterus. Dr. Thomas S. Cullen of the Johns Hopkins Medical School had been bold enough to state emphatically that a campaign of publicity had to be waged by the medical profession if the women of the country were to be made aware of the fact that in the early stages of the disease a large number could be cured by operation. A committee, with Cullen as chairman, had been appointed to correlate the various efforts which were being made in various states and cities and by several societies. A committee of the American Medical Association had reported in 1905 in favor of educational work regarding cancer. As a result, the Council of Health and Public Instruction was created by that association. At their annual meeting in 1912, the American Gynecological Society devoted one of its sessions to the discussion of cancer of the uterus. This society, too, appointed a committee to present a plan for publicizing information about the disease.22 After months of work, this latter committee reported that they were convinced that no permanent good could be accomplished except through the persistent efforts of an organized society, the objects of which would be not only to educate all lay people but to keep needed facts constantly before the family practitioner, because it was to him that the patient applied for what might appear as a slight and insignificant matter. A group of prominent laymen had become interested. Five individuals had guaranteed $5,000 toward the first year's ex-

22 The committee consisted of Drs. LeRoy Broun and Howard C. Taylor of New York and Dr. Fred J. Taussig of St. Louis. Fellowship of Surgeons 119 penses of the proposed society on the condition that the project be approved by the profession generally. The activities of Cul- len's committee and of delegates from other scientific medical societies finally culminated in the launching of the American Society for the Control of Cancer on May 22, 1913. Cullen had been able to enlist the interest and help of Samuel Hopkins Adams, who wrote an article, "What Can We Do About Cancer," in the Ladies Home Journal for May 1913. This was followed by similar articles in Collier's and McClure's magazines. For the meeting in Chicago, Cullen had prepared a symposium which was open to the public. Adams spoke on the subject, "Publicity Through the Lay Press." Doctors Reynolds and Greenough from Boston appeared on the platform with him and Cullen. The committee appointed at the New York Clinical Congress had taken active steps in starting an educational campaign and had promoted Adams' article. Cullen was not surprised when members of the local profession in Baltimore criticized him unmercifully and threatened to have him expelled from the roster of the Maryland Medical Society for unprofessional conduct. This meeting which laymen attended proved to be a huge success. The Board of Regents met on Thursday, November 13. The first convocation was to be held that evening. Immediately, the discussion concerned the admission of candidates to Fel- lowship. George Brewer had not been present at the Regents' meeting in October, when the fitness of the character of Joseph E. Blake of New York had been brought up for discussion by President Finney. However, on this occasion Brewer eloquently defended the professional and moral character of his fellow New Yorker. He was joined by Crile and Mayo. Finney, who was acting as Chairman, said, "As I have previously remarked, I brought the matter before the Board of Regents through a sheer sense of duty. I have considered Blake my personal friend and nothing but a deep sense of duty would compel me to make the objection I did. . . . I want to urge upon your consideration now, and at all times, of the position that every man whose name comes up here for 120 Fellowship of Surgeons Fellowship should occupy in the community not only from a professional but from a moral standpoint. . . . After saying what I have and on the strength of what Dr. Brewer has said, I withdraw any objection I may have made. . . . I do not think it is wise for us to devote any more time to the consideration of this case." Finney also asked his colleagues for a motion which would "strike all reference of the Roswell Park matter from the minutes." Other candidates less well known than Park and Blake were considered carefully and the evidence was weighed judicially. Objection was raised to Dr. Emery Marvel of Philadelphia because, it was said, he had a "commercial spirit." It was also reported that he had a tendency to advise operation and to insist upon it in cases in which it was not deemed necessary by the referring physician. The President informed Dr. Marvel personally of the charge and asked for a statement which he could read to the Board in rebuttal. Evidently, Dr. Marvel's statement was not convincing. To be completely fair in just such instances, these men voted to refer his application back to the Credentials Committee for further investigation. 23 As a result of the hours of soul-searching discussion, Ochsner asked that the Regents give his committee the right to send a statement to any candidate whose application had been deferred and to point out the defect in the candidate's credentials. Ochsner was seeking a method to give an applicant a period of probation sufficiently long to convince the Credentials Committee that he had reformed and had abandoned the particular practice which prevented his election to Fellowship. Grudgingly, the Board of Regents adopted Ochsner's motion. Franklin Martin had worked at high tension in preparing for the Clinical Congress and the first convocation. He had been interviewed by the press as the spokesman for the new College.

23 At the April 11, 1914, meeting of the Board of Regents in New York City, Dr. Murphy moved that Dr. Emery Marvel be admitted as a Fellow. The motion was seconded and, after considerable discussion, carried, Dr. Edward Martin voting "No." Dr. Ochsner made an informal suggestion that the candidate not be notified of his election until the day before the next convocation. Fellowship of Surgeons 121 The newspaper reporters had been given lists of the candidates to be inducted into Fellowship from their cities. Martin had been quizzed about the criticisms which had been made against the College. Among other newspapers, the Boston Transcript said: Dr. Martin answered his critics by declaring that it was impossible for him to believe that they were sincere in what they say. "The burden of their cry," Dr. Martin said, "is against what they claim to be our plan to classify the surgeons who become fellows of the American College of Surgeons into different grades. There is absolutely no such plan in our bylaws and I am convinced they know it but they grasp at a pretense of misunderstanding the situation in order to have a supposed cause of criticism. We started out with classes A, B, C and D, it is true, but that classification was only for purposes of organization. I made a mistake, I realize now, of using the word "class" in working out the plan of organization. I should have used the word "group" and each time I used it I should have explained that the term was used only for purposes of organization. . . . If there was to be a college some one had to originate the idea and some body of men had to be the founders. After they become fellows, they will all be on the same footing. It doesn't matter whether it be the most distinguished surgeon admitted as an honorary member, or the most inconspicuous young man admitted ten years hence by examination. Franklin Martin had been harassed by the 1,500 unsuccessful applicants for Fellowship who were at the meeting. At the convocation, 1,059 surgeons, including the Founders' group, were to be admitted to Fellowship. There had been clerical errors in the lists of names compiled for the program. Herbert Bruce, the Regent from Toronto, complained that the list of men to be admitted contained the names of men from Toronto to whom he and the other Founders from that city objected. Martin replied that a great deal of the fault was due to the group in Toronto. He had received only one letter from them and if the list contained the names of wrong men, it was purely and simply their own fault. Bruce admitted that the names were not considered as carefully when they sent the list to the 122 Fellowship of Surgeons Secretary as they thought was necessary later on in their deliberations. Nevertheless, the Secretary pointed out, the Toronto committee had taken no further action. During the luncheon interval on the day of the meeting of the Board of Regents, Finney asked Franklin Martin to come to his hotel room. Finney told him that since the organization of the College some six months before, he had received many letters and had talked with many interested surgeons. Every- one had been enthusiastic over the idea of the College and hopeful as to the good that it would accomplish in the profession, "but quite a number had said that, although the idea was all right, they questioned the wisdom of Dr. Martin's playing such an important role in its organization and management?" 24 These individuals had said they had no specific reason for this feeling about Martin, but Finney had concluded that there was a feeling that he wasn't just the man for the place. As President of the College, Finney wanted to have a heart- to-heart talk with Martin to know whether there was any reason why he should not continue in his office as Secretary. Martin replied that he knew there were a number of people who questioned his motives and even his integrity. He told Finney that he was conscious of nothing he had done in his professional life that would in any way reflect upon his honor or integrity. Finney said he was satisfied with the discussion between them. However, he pointed out that since there was opposition, it was conceivable that it might develop into serious proportions. In such an event, Finney believed it would be to the advantage of the College to have someone else in the Secre- tary's job. Finally, he suggested that, as President, he would be in a stronger position if Martin would put his resignation in his hands to be used if and when it appeared to Finney to be advisable. Without a word further, Martin sat down and wrote out his resignation as Secretary of the American College of Surgeons asking what date Finney would suggest for it to take effect. Finney asked him to leave it undated. They returned to the meeting.

24 Finney, J. M. T.: A Surgeon's Life. The Autobiography of I. M. T. Finney. New York, G. P. Putnam's Sons, 1940, p. 132. Fellowship of Surgeons 123 After completing the discussion on the remaining names proposed for Fellowship, the Secretary moved that the Chair- man of the Board of Regents appoint a committee to consider a permanent home for the American College of Surgeons. Up to that date, all of the records had been located and the correspondence carried on in offices rented in the same building at 31 North State Street, Chicago, where Martin had his professional offices. Martin did not believe that the permanent home of the College should be in Chicago at least for a number of years. He emphasized that the American Medical Association had its headquarters in Chicago and that almost every doctor of prominence was more or less connected with the future of that organization. He did not believe that these men could serve two masters. He expressed his disappointment that he had reluctantly come to that conclusion because he had pictured the home of the College on the beautiful lake shore in one of the city's parks. He thought that there was no question but that the College would have had unlimited support from the financiers of Chicago. Emotion overcame him. He continued by saying that though they might not agree with him about the site of the permanent home, he wished them to consider the fact that he did not wish to continue to serve as Secretary after the present term of his office expired on the following day. He said that the College was bound to grow rapidly and a paid, permanent Secretary was absolutely necessary to look after the organization's administration. Such a man, he said, as Livingston Farrand, then associated with the National Association for the Study and Preven- tion of Tuberculosis, should be chosen. Murphy was quick to recognize Martin's symptoms. When the Chairman asked for a second to the motion, Murphy replied that Dr. Martin had made an important suggestion, but it was really merely a suggestion. The Secretary interrupted, "It is more than a suggestion. It is my absolute conviction that this (Chicago) is the wrong place for the American College of Surgeons, and my considered opinion that a full-time secretary is necessary. That is my motion." Finney rescued the situation. "This is not the time nor place 124 Fellowship of Surgeons to put on record the opinion that this Board of Regents holds regarding the work that Dr. Martin has done in this connection. We are all a bit overwrought just at the present time under the excitement of this occasion, so that we cannot give proper expression to our feelings but the time will come for that." The first half of the motion was carried, and the Committee on a Permanent Home was created. The names of the initiates were read again individually, state by state and province by province. Ochsner verified that each had signed the register of Fellows. When the list was completed, William Haggard, the Regent from Nashville, asked if the American College of Surgeons admitted Negroes to Fellow- ship. He said that he noticed the name of Daniel H. Williams of Chicago on the list and he understood he was a colored man. Williams was on the staff of St. Luke's Hospital and was of such a light color that he could easily pass as a white man. He worked among his people and was highly regarded as a doctor of skill by the surgeons who had seen him operate and by the physicians at the hospital, including Robert B. Preble, one of the well-known internists at St. Luke's. Ochsner stated that the Credentials Committee believed Williams to be a first-class doctor in every way, ethically and professionally. The men on the committee were strongly of the opinion that the fact that he was a Negro should not bar him from Fellowship. Haggard pointed out that as far as he and his southern colleagues were concerned, it was a completely new departure in the United States and certainly, as a result, there would be an enormous number of Negro doctors who would apply for Fellowship. Finney was a southerner by birth and upbringing. "I appreciate the objection raised by Dr. Haggard," he said, "but every tub must stand on its own bottom. The Regents must rise above everything except the consideration of professional fitness for Fellowship." Haggard emphasized the social implications about which all southern doctors would feel keenly. Cotton of Boston appreciated Haggard's point of view and thought there would be so few Negro doctors eligible for Fellowship that the College Fellowship of Surgeons 125 would be throwing away a good deal to gain a little. Haggard made a strong presentation of the social problem involved and the train of evils which would follow, which then could not be cured. He could see no reason for admitting one colored surgeon and alienating all of the surgeons of the South at a time when the College was trying to get off to a good start and gain the confidence of the profession. Ochsner immediately threatened to resign if Williams were not accepted, declaring that he was "absolutely straight." Hag- gard denied any personal animus toward Williams but insisted that a principle was involved. Murphy suggested that Williams' name be held for future consideration. Ochsner again threatened to resign if they took that step. Brewer of New York differ- entiated between Haggard's statements about social equality and the question of whether the individual qualified professionally. Murphy's suggestion to consider Williams' name later would never have passed as a motion. It was an issue which they agreed had to be faced and decided at that time as a principle to be followed. Haggard resolved the situation by saying, "I thought it fair to state my feelings with regard to this matter. I appreciate kindly what Dr. Ochsner said, and I know from what Dr. Ochsner says this man is all right. I know Booker Washington is all right, but at the same time where we live we cannot invite him to our homes. We never can during the present state of things, and the same with this gentleman, although I have never seen him. I feel it is right to have said what I have, and I wish to make a protest on behalf of a section of the country which I have the honor of representing on this board. I do it purely and simply from convictions, and without any idea of antagonizing the board, and particularly Dr. Ochsner, who has really done a great work in this organization. With that, Mr. President, I wish to say that I am sorry to have taken up so much of the time." Ochsner stated his position a bit more clearly in his reply to Haggard's final remarks on the subject, "I am sorry I spoke as 126 Fellowship of Surgeons I did. But this man is absolutely an A-1 man and he is as white as any man. If you met him on the street you would hardly realize that he is a Negro. I have been up against him over and over again. I do not operate on Negroes because I do not like them; I do not want to have anything to do with them. If any Negro patients come to me, they are referred to him, and he takes care of them. He is one of the finest fellows I know." Haggard of Nashville, Tennessee, undoubtedly had some difficulty determining Ochsner's views and the reasons for his first uncompromising, arrogantly stated opinion accompanied by threats. President Finney was glad to be able to adjourn the meeting of the Board of Regents so they could attend the session of the Board of Governors, which they spoke of emphatically and proudly as the corporation. Again, the bylaws were read section by section and article by article, and the few amendments made were explained in detail. Bevan of Chicago, who had been made a Governor, moved that the constitution and bylaws be adopted as read, and Miles Porter moved that the present officers be re-elected. In only a few hours, the first convocation of the new College would be held. Martin reviewed the events which had to do with the Clinical Congress. A report of the 2,591 registrants at the meeting in New York the previous year had been made. A statement of receipts and disbursements for that Clinical Congress had been audited by a competent firm and read to the assembled doctors. Now it remained to have a dignified academic atmosphere surround the convocation. The following day, officers for the next Clinical Congress would be elected. At that moment, the difference between the new College and the Clinical Congress would have to remain, but Martin has said that in his own mind there was no question but what the Congress should represent the scientific part of the College. Also, at that moment, each candidate would have to sign the Fellowship pledge and a declaration against fee-splitting. Mar- tin hoped that the Professor of English at Princeton University, to whom Finney had taken for revision the oath which Martin Fellowship of Surgeons 127 had written so clumsily, would write such a spine-tingling pledge that they could settle on one which would express all of the ideals of the College over which he had struggled so long.* The convocation was even more impressive than Martin had imagined. The large class of Fellows stood while the Presi- dent conferred Fellowship upon them. Chipman of Montreal presented Godlee. Crile of Cleveland introduced Keen, and Stokes of the Navy acted as Halsted's cicerone as Finney received them and conferred the Honorary Fellowships.** J. Col- lins Warren of Boston and Robert F. Weir of New York received the Honorary Fellowship in absentia because serious illness prevented both from attending. Before giving his inaugural address, Godlee read a greeting to the American College of Surgeons from the Royal College of Surgeons of England.' He traced the history of the development of surgery in England from the beginning of the four- teenth century. He told of the Barbers' Company and the Guild of Surgeons which gave and took away licenses to practice surgery. Queen Victoria had granted a charter to the existing Royal College in 1843. It was an informative address which needed to be given to the new College which would suffer many labor pains as it attempted to define and carry out its ideals and functions in the future. Godlee told them that as a College it would indeed be fortunate if they escaped the criticisms which sometimes had been made against the Royal College of proceeding "either with too great temerity or with excessive caution." Finney delivered his presidential address which was printed and distributed to each Fellow and to the profession at large. . . . What is consummated here tonight is destined to produce a deep and lasting impression upon medical progress not alone in the United States and Canada but indirectly the world over.

° See Appendix, Chapter 3:5. °° See Appendix, Chapter 3:6. *** See Appendix, Chapter 3:7. 128 Fellowship of Surgeons . . . We have pictured to ourselves in this connection a profession ennobled by men actuated solely by their desire to devote their time and their talents to the relief of suffering humanity, willing, yes, glad at any time, if need be, to lay down their own lives for those of their fellow-men; whose membership should embrace only men of singleness of purpose, unselfish, high-minded, zealous in their efforts to wrest from nature the keys to her many mysteries, men who unconsciously, perhaps, in character and conduct, reflect in varying degree the life and spirit of the Great Physician; a profession free from taint of commercialism or graft, in which there shall be no room for the base, the unscrupulous, the ignorant, or unskilled; in which the test for membership has to do only with character and attainment. . . . The aim of this organization and the reason for its existence lie in its disinterested and unselfish efforts to elevate the standards of the profession, moral as well as intellectual, to foster research, to educate the public up to the idea that there is a difference between the honest, conscientious, well-trained surgeon, and the purely commercial operator, the charlatan and the quack; furthermore, that the term "surgeon" means something more than a suave manner, a glib tongue, a private hospital, a press agent, and the all too easily acquired diploma, with its accompanying title of "doctor." .. . Finney ended his vigorous and almost evangelistic address to the new Fellows by saying that the public and professional minds should be disabused of any wrong impression that the College was to be run by any one man or set of men, or by or in association with any pre-existing organization for his or their personal gain or aggrandizement. He pledged that the College would always stand only for the good of humanity and the elevation of the professional standards of surgery. It was an enthusiastic audience which left the Gold Room of the Congress Hotel. Martin at last felt that Finney would be a fighting defender of the College; that he had become convinced of the great good to be accomplished in the manner in which Martin had dreamed of it. The Clinical Congress of Surgeons finished the following day Fellowship of Surgeons 129 after accepting an invitation from Sir Rickman Godlee to hold the fifth meeting in London. Those doctors in attendance elected unanimously the officers presented by the nominating committee under the chairmanship of Finney. Murphy became President and George E. Armstrong of Montreal, Vice-Pres- ident. The visitors to Chicago had been able to buy their lunches for 20 cents. A section in one of the newspapers was devoted to income tax puzzles for the readers to solve. They read that the number of automobile deaths in Chicago had increased six times in the previous five years. Ochsner had to assure a Chicago Tribune reporter that the aim of the Clinical Congress was not to take up the subject of quack doctors which that newspaper had been exposing. Some individuals were worried because there had been a slump in the stock market prices which was attributed to the belief that a crisis was approaching in the relations between the United States and Mexico. However, they could all go home for Thanksgiving relaxed and cheerful, if they had read the Chicago Tribune's daily health column on the editorial page. Drink neither wine, beer nor whiskey with the meal. Eat slowly and chew food well. Eat lightly of the earlier courses. Do not eat the dressing; it taxes the digestion all out of proportion to the excellence of its taste. Drink a quart of water during the meal; all of that food must go into solution and water is needed. After dinner is over, get plenty of air in the room. Drink plenty of water after dinner. Be sure to have plenty of chewing gum on hand. Begin chewing about an hour after dinner and chew until the fullness disappears from the region of the belt. About two hours after eating, go for a walk in the open air. If you begin to sneeze, be certain to get out into the fresh air. Finally, if you wish to escape a bilious spell the next day, take a dose of castor oil before retiring. Certainly, the visitors were right in thinking that after the week of intensive postgraduate work, Chicago was chuck-full of medical advice, medical teaching and medical organizations. It all tended to make a plain doctor man confused. CHAPTER 4

FTERTHE first convocation of the American College of Sur A geons, a storm of criticism broke in the Bulletin of ilk Chicago Medical Society.' An article written by Dr. Henry F Lewis was entitled, "The Royal Americans." Lewis said in part, "We understand that the king is going to pull off some sort of a durbar here in Chicago. Probably his majesty will not preside in person. But his ambassador will be here to act as viceroy, none other than the First Lord of the Admiralty of the Royal College of Surgeons, resplendent in his robes of state. He will be empowered to give the accolade to the chosen few among our surgical friends and neighbors who have been selected by an all-wise something-or-other to be founders of the American College of Surgeons. In other words, with great flourish of trumpets and popping of corks there will be introduced to an amused and unfeeling professional world the latest product of medical snobbery in America." Philip Mills Jones struck again in the California State Journal of Medicine. 2 The price of the gown awakens no suspicion of the splendor it will purchase. It is $11.90. . . . We fancy we see a propen- sity to prodigality checked by prudence; magnificence there must be, though not at any price, and magnificence there will be. For we read: "Body of Gown, navy-blue mohair. A scarlet velvet facing five inches wide extends around the neck and down each side of the front. The Cap is of same material as Gown with scarlet tassel."

1 Bull. Chicago M. Soc., 13:6, 1913. 2 Editorial, California J. M., 12:2, 1914. Fellowship of Surgeons 131 A resolution deprecating the founding of the American Col- lege of Surgeons was introduced in the House of Delegates of the American Medical Association by the Illinois delegation. This and a substitute resolution to the same effect were tabled. 3 A resolution proposed by John Ridlon, an orthopedist of Chi- cago, was adopted by the Chicago Medical Society. It asked that the committee appointed on November 18, 1913, to investigate the relations existing between the Chicago Medical Society and the American College of Surgeons be given $1,000 to meet its necessary expenses. As the background for his resolution, Ridlon cited the charter of incorporation, the oath, the names of the 103 members of the Chicago Medical Society who had been granted Fellowships in the College, and excerpts from The Chi- cago Record-Herald and The Chicago Examiner in which Franklin Martin and John B. Murphy were quoted. Branches of the Chicago Medical Society were urged to get into the fight. The complaints of one of these branch societies were more specific:

WHEREAS, It is known that there has been recently organized a society or organization known as the American College of Surgeons, and whereas members of the Society are to be known as the fellows of the American College of Surgeons, and whereas the present members are self-recommended and self-elected without examination, and whereas the purpose of such society seems to be to make itself judge of who shall or shall not be qualified to practice surgery in America, and whereas it is known to the physicians and surgeons at large as good work is being done by surgeons outside of the self-elected surgeons comprising the membership of the above named American Col- lege of Surgeons as is done by said members, and whereas said society is un-American, and whereas said society is un-Demo- cratic, and whereas said society is un-ethical according to the standard of American physicians and surgeons, and whereas such society is unjust and inequitable, and whereas the effect of such society will be to divide the surgeons of America into classes or castes, thus to destroy and disturb the harmony which

3 Fishbein, Morris: A History of the American Medical Association. Philadelphia, W. B. Saunders Company, 1947, p. 283. 132 Fellowship of Surgeons should prevail, and whereas the said society of self-elected judges purposes to arbitrarily say to what class any individual surgeon may belong, and whereas such action will create the idea among the laity that only members of the American College of Surgeons are qualified to practice surgery, and whereas this Society or movement, so far as the Chicago Medical Society and the Illinois Medical Society is concerned, is but another effort of a few so-called self-elected aristocrats to dominate the Chi- cago Medical Society and the Illinois Medical Society; whereas the American College of Surgeons threatens injury to the great mass of physicians and surgeons that position and profit may accrue to its self-elected members, and whereas we, as a component part of the Chicago Medical Society and the Illinois Medical Society, believe that the above named American Col- lege of Surgeons is injurious to both the profession and the laity; therefore, BE n. RESOLVED, That we object to and protest against the formation of such society as the American College of Surgeons. Be it further resolved that we will in every way possible stand for the great mass of legally qualified surgeons throughout the country against the self-elected members of the American Col- lege of Surgeons, and be it further resolved that we will work in every legal and ethical way possible to unite the members of the Chicago Medical Society, the Illinois Medical Society and of the American Medical Association throughout the different states into a unit against the above named American College of Surgeons and its individual members and against the principle for which the American College of Surgeons stands. . . . Letters were written to the Illinois Medical Journal, the tenor of which was that the College was an oligarchy for the purpose of controlling honors, titles, offices and business. 4 Editorially, this journal admitted that better surgery was needed. However, the plea made then and repeated many times since was that further advances should come through the various state boards of health and should be furthered by appropriate committees of the American Medical Association which is made up of component state and county medical societies.

4 Noble, William L.: Letter to the Editor, Minois M. J., 24:5, 1913. Fellowship of Surgeons 133 It was feared that an organization which would be competitive in influence with the American Medical Association had been founded. It was certainly expedient and indeed wise for the critics to say that better surgical work was really needed. They were obliged to come out against sin. From no source was a plan offered which was a counter-suggestion to the formation of the College and which would accomplish the same goals. While the protests were vigorous and often repeated that the opposition was against the College because of the undemocratic and un-American principles which it fostered, the real underlying difficulty seemed to be money. Patients would seek well- trained surgeons in well-equipped and efficiently administered hospitals. There was a real fear that practices would shrink. What were the motives of the men who founded the Amer- ican College of Surgeons? Why did they spend so much time discussing commercialism and fee-splitting if these were nonexistent facets of surgery? Were adequate records kept on patients in hospitals? Was there unnecessary and poorly performed surgery? Was there an opportunity to elevate the standards of surgery by insisting upon adequate training for those who wished to become surgeons? Walter W. Chipman, one of the first Regents has said, "The aim was to make the College generously representative and, while imbuing it with the right ideals, to secure for it the support of the great bulk of the profession. . . . From the beginning, the College has concerned itself with problems of education. First, of course, the education of ourselves within the College in order to increase in every way our surgical attainment and then to engage in the large education of the laity without." Rudolph Matas pointed out that the College had to cope with existing evils when it was organized. Conditions were far from ideal and were actually injurious to the profession. Matas said, "The practice of surgery has been and is beset with evils which obstruct its progression and cloud the splendor of its achievements. The main purposes of the American College of Surgeons are moral and humanitarian. They are built on the 134 Fellowship of Surgeons principle that individual or private interests must be subordi- nated to public welfare and any deviation from this principle is destructive of its very existence as an organized agency for the public good." More of a philosopher perhaps than his fellow Regents, Matas believed that the gravest evils existing in surgery were those inherent in human frailty and credulity. The other evils, he thought, were the outcroppings of the over-luxuriant growth of a nation which is composed of heterogenous elements which it has had to assimilate and transform into a citizenry capable of adapting itself to the requirements of its political, social and economic structure. George Crile believed it to be the task of the American Col- lege of Surgeons to see that there were good surgeons throughout Canada and the United States and that wherever a human being required the services of a surgeon, there should be a good surgeon and a good hospital. William J. Mayo pointed out that he, though not a Regent, realized that the founders of the College wished it to be opened for Fellowship to all those men of "sterling character, ability and training in general surgery and in the various surgical specialties who are within the limits of North America." The College was the result of need for a reform from within, undertaken to make the surgical world a safer and a better place. Chipman said in 1938 after he had served the College for 25 years, "Two ways were open to us, either to follow tradition and exact a scholastic examination, again an exclusive hierarchy, or, on the other hand, to create from the beginning a surgical commonwealth, the members chosen for their character, their actual work and their experience. I shall always believe that very fortunately our young College chose the latter course for, in so doing, it drew together the many surgical associations, gave them an axis as it were and also secured the influence and the weight of the whole profession." Some editors and medical journals defended and supported the purposes of the new College. The Journal of the American Medical Association confined its statements strictly to news re- Fellowship of Surgeons 135 porting.5 In fact, its editor, George Simmons, had told Franklin Martin that he had no alternative because of the great influence certain members of the Chicago Medical Society and the Illinois State Medical Society possessed. The American Medical Association consists of a confederation of county medical societies throughout the states of the union. In some instances, the state medical society issues a charter to a county society; in others, the county group is quite independent of the state organization. All disciplinary problems which might arise concerning poor surgery, fee-splitting or unnecessary surgery must originate within the local county society. Steps for the expulsion of a member of this large medical organization for unprofessional or unethical conduct cannot be initiated by its Board of Trustees. It was known then, and has been confirmed in later years, that often state medical societies wrote or interpreted their own code of ethics irrespective of that written and upheld by the Judicial Council of the American Medical As- sociation. Thus, the comments pro and con were the opinions of the profession in local areas based upon such data as they wished to assemble before making such interpretations as they might be influenced to express. The Journal of the Michigan State Medical Society congratulated the organizational committee on its work and achievement and urged the hearty and earnest support of the profession in Michigan. It prophesied that the College would become a potent factor in maintaining a high standard for American surgery.° An editorial in Colorado Medicine stated:7 . . . It may be many years before the somewhat Utopian aims of this organization can be wholly realized; and, indeed, they may never be fully and completely attained as set forth in the call for the first meeting. . . . That such an organization should

5 Medical News (General), J.A.M.A., 50:19, p. 1471, 1913; 50:20, p. 1552, 1913; 61:4, p. 288, 1913. ° The American College of Surgeons (Editorial), I. Michigan M. Soc., 12:8. 1913. Editorial, Colorado M.,11:10, 1914. 138 Fellowship of Surgeons excite criticism and resentment from some whose point of view makes it difficult for them to see its necessity, or whose methods do not conform to its requirements, goes without saying. The Canadian Medical Association Journal was analytical in its comments:8

. . . So long as the college is hortatory it will succeed. So soon as it attempts to become mandatory it will fail. Its value will depend upon the character of the surgeons who compose it. It will depend also upon the character of the surgeons who do not compose it. At the moment, it is more important to the college that it should include all good surgeons than it is to the good surgeon that he should be included. Therefore, no good surgeon need fear that he will not be invited to join. . . . Again, in the statement of October 23rd, much is made of the "absolutely democratic origin" of the college; and we are instructed that the mark of a democratic body is that it is "open," and not "selective." The committee protests too much. If the college is not a selected body, it has no reason for existence. The truth is that the selection was carefully made. The committee selected three persons in various localities to select those who might be invited to become founders of the college. By a further process of selection, a list of Fellows was finally evolved and published on November 13th. If this were the end, the assumption of the new college that its members alone were qualified to perform surgical operations, would be monstrous. But it is not the end, and new names are being brought forward daily. The design is correct; but patience on the part of the profession and wisdom on the part of the college are required. Without any doubt, the small group of men, at first somewhat reluctant to share completely in Franklin Martin's vigorous enthusiasm to found an organization which would do more than give lip service to higher standards and ideals in surgery, was now being regarded as impractical visionaries and dangerous autocrats by the large majority of practicing physicians. The latter wished only to remain under the sheltering cover of the

8 The College of Surgeons (Editorial), Carved. M. A. I., 4:1, 1914. Fellowship of Surgeons 137 all-embracing official organization of the medical profession which could not take disciplinary action. It appeared that the majority of the Regents at their first meeting had adopted the attitude that the College of Surgeons was organized primarily to combat an evil of the profession- fee-splitting. Franklin Martin had pointedly told them that there were other principles which needed emphasis in the pledge which the candidates were to sign. Doctors needed to be trained to become surgeons and this training should include their talents, skill, morals and ethics. But fee-splitting was prevalent and it was much easier to give vent to the emotions when one opposed evil. How to educate young men to become surgeons by a residency system, such as William S. Halsted had instituted at the Johns Hopkins Hospital, or by a more individually preceptorial system which utilized the preceptor's patients, required calmer and more logical discussions. It was all well and good for Franklin Martin to continue to insist upon raising the standards of those men who were then performing surgery. The Clinical Congresses had given practical proof that the meetings could add tremendously to the education of the surgeon in practice. The answers to the other questions which involved the recent graduate who wished to become a surgeon were not so easily solved. So the Regents discussed at length the subject of fee- splitting which had been in the lay and medical press for many years and on which no concrete action had been taken by the American Medical Association to eradicate the practice. Though the first laws governing the practice of medicine date back to the Code of Hammurabi in 2500 B.C., the popularly accepted code of ethics is associated with Hippocrates and The Oath which has been well publicized. However, as Smithies stated, the Hippocratic Law is a more illuminating memoir of ethical principles, but less well known. . . . Their mistake appears to me to arise principally from this, that in the cities there is no punishment connected with the practice of medicine (and with it alone) except disgrace, and that does not hurt those who are familiar with it 188 Fellowship of Surgeons Instruction in medicine is like the culture of the productions of the earth. For our natural disposition is, as it were, the soil; the tenets of our teacher are, as it were, the seed; instruction in youth is like the planting of the seed in the ground at the proper season; the place where the instruction is communicated is like the food imparted to vegetables by the atmosphere; diligent study is like the cultivation of the fields; and it is time which imparts strength to all things and brings them to maturity. Having brought all these requisites to the study of medicine, and having acquired a true knowledge of it, we shall thus, in traveling through the cities, be esteemed physicians not only in name but in reality. But inexperience is a bad treasure, and a bad friend to those who possess it, whether in opinion or reality, being devoid of self-reliance and contentedness, and the nurse both of timidity and audacity. For timidity betrays a want of powers, and audacity a want of skill. There are, indeed, two things, knowledge and opinion, of which the one makes its pos- sessor really to know, the other to be ignorant. Those things which are sacred, are to be imparted only to sacred persons; and it is not lawful to impart them to the profane until they have been initiated in the mysteries of the science.° It was not until the foundation of the American Medical As- sociation on May 5, 1846, that anything like a uniform national code of ethics or practice was recognized. This organization published a code based upon Sir Thomas Percival's Medical Ethics published in 1803. It was a mixture of etiquette and ethics, which dealt mainly with the amenities of social inter- course between physicians, at the same time inoffensive, confusing and ineffective. Social and economic problems were changing rapidly. This code was amended in 1912 to condemn commissions for the referral of patients and to prohibit the secret division of the patient's fee. It was not difficult, however, for the determined physician to devise a method to obviate the limited proscriptions which were set down.

9 Smithies, Frank: On the Origin and Development of Ethics in Medicine and the Influence of Ethical Formulae upon Medical Practice. Ann. Clin. M., 3:9, 1925. Fellowship of Surgeons 139 Prior to the founding of the American Medical Association, innumerable local medical societies had been formed. Each group endeavored as best it could to regulate and guide practitioners with ideas, principles and ideals which clashed with their customs. It is remarkable that in early American medical practice a small number of high-minded men were sufficiently powerful to prevent the medical chaos and quackery which in the beginning were common to France, Germany and England. At the turn of the twentieth century, the practice of the division of the patient's fee began. It would have been difficult for the surgeon or physician to exploit the surgical patient in earlier days because an operation was such a hazardous procedure. "Going under the knife" was a terrifying phrase. The patient would not agree to submit to an operation, nor would a doctor recommend surgery, unless the situation was critical to the point that it was almost beyond recall. Antisepsis and better methods of anesthesia made a surgical operation safer. The patient could go to a hospital, have an operation and return home better as the result of the experience. The surgeon was placed on a financial pedestal which was not shared by the less spectacular family doctor and his black bag of medicines. An operation was a big and important event in the patient's life. The innumerable calls at the home and the skill needed to make a diagnosis and decide that an operation was necessary were commonplace. Patients were willing to pay well for a surgical operation but balked at paying more than a low rate for the physician's visits. As in other complicated social problems, the public itself to a certain extent was to blame for the existing conditions. If the laity had compensated the family physician fairly and promptly for his services and had insisted that all financial transactions be discussed with them, the cause and the evil would have quickly disappeared. Mounting surgical fees resulted in an increase in the number of surgeons. As Martin insisted, this increase unfortunately was not based on any special fitness to practice surgery. There could be only one result, an overcrowded field of medicine which was filled with the incompetent and the commercially minded. 140 Fellowship of Surgeons If the number of these improperly trained and poorly qualified physicians who operated upon patients became large, the task of the layman in choosing his surgical advisor would become hopelessly difficult. There were many other objections and difficulties from which the patient would eventually suffer. The medical school graduate, who might wish to become a surgeon and who would have to spend several years in preparation and more time in establishing a reputation for careful, honest work, could take the easier way. He could join the group of fee-splitters and soon secure a large business from his practice. Patients would be diverted from the well-qualified surgeon whom they might prefer. Damnation with faint praise or even open lies about the experienced, honorable and accomplished surgeon were mixed with unbounded praise of the inferior unknown who would accept a proposition. Exorbitant fees were explained to the patient as due to the "wonderful difficulty of the operation" or because the surgeon was "the only man in the city who would have undertaken the case" or who had "the necessary skill to carry it through." It appeared apparent that physicians who descended to the buying and selling of patients seldom had any scruples at the performance of unnecessary operations. The fee was the main objective. There was little or no regard for the welfare of the patient. The effect upon the medical profession was demoralizing and the public was becoming increasingly well informed. In 1900, two members of the Chicago Medical Society, wishing to expose the extent of fee-splitting, sent to 100 Chicago doctors a letter which purported to have come from a country doctor in Illinois. The writer described himself as young and in need of money. He wrote that he had a wealthy patient whom he wished to bring to Chicago for a consultation. Would there be a 25 per cent commission for him on the fee collected by the consultant? The answers were published in the newspapers and the scan- dal shook the city. Members of the medical society were an- Fellowship of Surgeons 141 noyed because John B. Murphy, whom they were accusing of all the varieties of unethical practice, was among those who had refused to give a rebate on the fee. In the end, the medical society, to its discredit, disciplined the two men who had con- cocted the hoax and allowed those who had revealed themselves as fee-splitters to go undisciplined. In 1911, The Journal of the American Medical Association published an editorial concerning this problem which then and now is non-existent in many localities of the United States." The giving and receiving of secret commissions has been discussed with increasing frequency for several years. Although the existence of this practice has long been recognized, we have always believed it has been confined to a comparatively small number of physicians. Condemnation of this evil by the association, by The Journal, and by various medical societies, as well as occasional local investigations and exposures, have apparently failed to abolish it. Recent discussion shows that the better men in the profession appreciate the importance of the problem and the need of its solution by physicians. In this issue appear two articles on the subject, one the president's address before the Western Surgical Association, ( 11 ) and the other an editorial from Colorado Medicine. Both of these articles are severe and carry the impression that the practice is widespread. We are loath to believe that conditions are as bad as represented. Yet this evil, if existent to any extent, should be freely discussed and unsparingly condemned. Its correction is of vital importance to the public as well as to physicians. While it has long been recognized as existent by the profession, the rapidly growing interest of the public in professional matters and the increasing disposition of physicians to take the people into their confidence, have apprised the public, apparently for the first time, of the existence of this condition. Now that the people are informed, the evil must be speedily corrected by the pro-

10 Editorial, J.A.M.A., 56:10, 1911. " In his presidential address given in Chicago, Dr. John Prentiss Lord of Omaha, Nebraska, president of the Western Surgical Association, discussed the "secret commission evil." This association incorporated a clause in the application blank requiring the applicant to state that he did not practice fee-splitting, would abstain from doing so in the future and would not countenance it in others. 142 Fellowship of Surgeons fession, for if it is not, the people themselves will demand the right to suppress it. In 1912, the Judicial Council of the Americal Medical Associ- ation, under the chairmanship of Dr. Frank Billings of Chicago, proposed a revision of the Principles of Medical Ethics. Article VI, Section 4 was written to read: "It is detrimental to the public good and degrading to the profession and therefore unprofessional, to give or to receive a commission or to divide a fee for medical advice or surgical treatment unless the patient or his next friend is fully informed as to the terms of the transaction. The patient should be made to realize that a proper fee should be paid the family physician for the service he renders in determining the surgical or medical treatment suited to the condition and in advising concerning those best qualified to render any special service that may be required by the patient." This appeared to legalize fee-splitting if the patient was informed, and at the same time spoke eloquently for the rights of the family doctor. Local groups became more and more direct in their attempts to solve the problem. In Los Angeles, the county medical society demanded that each member sign a pledge that he would not participate in fee-splitting. The New York Academy of Med- icine passed a strongly-worded resolution on the subject. In Detroit, the board of trustees of Harper Hospital passed a rule that any member of the medical staff convicted of the secret division of fees should be dismissed. The faculty of the medical school of the University of Minnesota strongly denounced the secret division of fees and declared the practice, tantamount to the buying and selling of patients, to be "disgraceful and ab• horrent to every right minded practitioner and the gravest danger that threatens the profession." These were well meaning acts and statements which could salve the conscience of those who made them and, having issued them, they could easily assume they would become a matter of accomplishment. To obtain a license to practice medicine, the individual needed only to have been graduated from a medical school and pass a written examination. He then had Fellowship of Surgeons 143 the legal right to operate upon a patient. The training of men to become qualified experienced surgeons could play a strong role in developing individuals with strong moral and professional ethical principles. A graduated and progressive system of training for surgery had been initiated at the Johns Hopkins Hospital in Baltimore by Halsted. When the aspiring student of surgery had finished such a training program in residency at the hospital, he was well qualified by experience and teaching to perform operations. Such training programs were scarce. The majority of medical school graduates had no training experience. They gained their experience upon their patients. There were others, increasing in number, who became assistants to older experienced surgeons and were taught by them. More often than not, these young men became servants of the master, who did not assume the full responsibilities and duties of a teacher and preceptor and who often made the young man agree never to practice surgery within a given distance of his benefactor's office. Franklin Martin was convinced that the teaching of surgery was a postgraduate function and that the university and other medical schools should assume this great responsibility. Cer- tainly, this involved the close affiliation, if not ownership, of the medical school and a hospital. Demanding certain high qualifications of training for Fellowship in the American College of Surgeons might result in the assumption of these teaching duties by the faculties of all of the medical schools. Much remained to be done, and Franklin Martin was aware that unless the policy-making Board of Regents met frequently, the movement would fail by inertia. A special meeting of the Board of Regents held at The Waldorf-Astoria hotel in New York on January 9, 1914, approved Edward Martin's committee's recommendation for the admission of candidates to Fellowship, which stated: After November 1, 1914, an applicant for Fellowship in the American College of Surgeons in addition to filing and signing the regular application blanks and declaration and receiving 144 Fellowship of Surgeons regular endorsement as to surgical efficiency and ethical probity now required, must present to the Committee on Credentials a detailed statement of his surgical training and experience and a duplicate statement of operations performed by him, with the immediate and, as far as possible the remote results. Should the evidence then presented satisfy the committee, the candidate will be recommended to the Board of Regents for examination in physiology and surgery. Notification as to the time and place of such examination will be sent to the candidate. In accordance with the current form, the committee on examination will then either recommend the applicant for election or reject him on recommendation by the Committee on Credentials. On unanimous vote of the Board of Regents a candidate may be admitted to Fellowship without examination. This would require work, an efficient organization and financial support. It was recommended that President Finney name a committee, of which he would be the chairman, to obtain an endowment from the Carnegie Foundation, or some similar organization, for the purpose of carrying on the work of the American College of Surgeons. After the tense meeting in Chicago the previous November at which Finney had obtained Franklin Martin's undated resignation, a fact known only to them, Martin had allowed himself to be re-elected Secretary. He had persisted in urging that the Regents consider establishing a permanent home for the Col- lege. At the meeting in New York, Regent Charles F. Stokes, Surgeon General of the Navy, reported that his committee had considered several questions which had governed their deliberations. What would be the fundamental purposes of a permanent home? Was the home to be a center for laboratory, hospital and clinical work, or was it to serve as an office to get at the qualifications of men, to publicize the work of the College, to house a general secretary and to be free from the influence of local medical politics? Which locality would give the greatest dignity to the College? Where would the greatest number of Fellows be likely to gather at one time and at stated intervals? Fellowship of Surgeons 145 What city could be considered most centrally located? What features of a center would be most advantageous for the College? George Crile presented an enthusiastic plea for Cleveland, at the same time diplomatically pointing out the advantages of Washington, D. C., Chicago, St. Louis, Philadelphia and Boston. One by one he ruled them out of consideration. Cleveland was blessed with the great Western Reserve University. It was the center of the eastern half of Canada and the United States, in the midst of a network of railroads with all lake navigation connections and possessed a pleasant summer climate. Herbert Bruce extolled the virtues of Washington. Murphy thought that all of the cities mentioned would be highly desirable but that Chicago should be ruled out because the home of the American Medical Association was established there. Practical as always, Franklin Martin reminded his fellow Re- gents that a large endowment should go with the permanent home. Another meeting of the Regents was held in New York on April 11, 1914. The Regents had been petitioned by the Ameri- can Institute of Homeopathy for representation on the Board of Governors. They had listened to representatives of the homeopaths and had argued fiercely pro and con. There were Fellows of the College who had graduated from homeopathic medical schools. They had been admitted to Fellowship only after long debate and personal appearances of their spokesmen before the Board. The majority opinion prevailed that members of the In- stitute who were Fellows of the College could be nominated to represent it upon the Board of Governors. Edward Martin's committee on the examination of future candidates realized the difficulty of obtaining money to carry on the proposed examinations of candidates for Fellowship. He reported that an actual examination was undesirable and that the minimum standard should be the record of the candidate's practice as judged by a list of 100 operations, with the tabulated results of those operations. It was necessary for Franklin Martin to make these recommendations specific and then to get 146 Fellowship of Surgeons the approval of Edward Martin and his committee before see ing adoption by the Regents. Finally, five proposals were written out in detail and adopt to carry out the committee's general recommendations: 1. Evidence that the applicant has served at least one year as a hospital intern and three years as assistant, or one year as first assistant to a surgeon of recognized ability and with an adequate hospital service. From those who were graduated before 1915, an equivalent surgical experience shall be acceptable, especial importance being attached to laboratory and research work. 2. Evidence that he has visited other surgical clinics and laboratories than those to which he has been officially appointed, giving the dates of such visits, the time spent, and a brief summary of the work witnessed or performed. 3. An abstract of at least 50 consecutive major operations which he has himself performed, this abstract to contain the name and address of the doctor or consultant referring the case; the preoperative diagnosis; the anesthetic given, by whom, the quantity, and the time of administration; the date of operation, and a brief description of it, with a note of the time required for its performance, calculated from the first incision to the beginning of the application of the dressing; the post-operative course, and a mention of complications, if such occurred; not only those conditions usually classed as such, but consecutive bleeding which calls for measures directed toward its control, hematoma of sufficient extent to require evacuation or drainage or suppuration, as slight even as a stitch abscess, are to be regarded as complications; the condition on discharge from the hospital with the subsequent course of the case up to the date of application for membership, or as near this as is practicable. The applicant shall supplement his individual report of operations by a further abstract report of at least 50 cases in which he has acted as assistant. 4. All applicants for Fellowship to the American College of Surgeons whose date of graduation is 1920 or later, shall be graduates of medical schools, which shall have demanded of their matriculates, two years of collegiate training, or the equivalent, including biology, chemistry and physics. If the candidate's school of graduation be not accredited by the American Fellowship of Surgeons 147 College of Surgeons, he shall be required to pass a technical examination. 5. Surgeons widely recognized by the profession as leaders of progress and exponents of finished technique, by a unanimous vote of the Regents, may be admitted to Fellowship on recommendation of the committee on examination. A method of passing upon the applications of men seeking Fellowship in the College was at last written down to guide the credentials committees in the states and provinces. These were high requirements to be met at the time. The effect of the Flex- ner report upon the standards of medical schools was anticipated in the requirement that after 1920 the applicant be graduated from a medical school which required two years of collegiate work for admission. The assumption that the records kept upon patients would be a competent yardstick by which to measure the surgeon's ability was to prove false. However, the insistence that this is a way of measuring the surgeon's care of his patient and his results, originally pronounced by Codman's committee, led to the campaign to elevate the standards of hospitals. Franklin Martin had the staff of Surgery, Gynecology & Ob- stetrics hard at work on plans for the Clinical Congress which was to be held in London in the middle of the summer of 1914. A. D. Ballou, the business manager, had become expert at making arrangements for meeting halls and at satisfying the doctors who attended the clinics and those who were like tempera- mental actors when they presented papers. Ballou was particularly effective in arranging for the luncheons and dinners which Martin was convinced played a great role in binding together the Regents, Governors and Fellows in a unified effort to raise the standards of surgery. Martin had questioned Ballou about the possibility of employing moving picture films in the program of the Congress. Films with stories of interest were now being shown in theaters. Francis X. Bushman and John Barrymore were starred in films appearing in Chicago. A notice in movie advertisements usually carried the admonition "The chance of a film not reaching the 148 Fellowship of Surgeons theater on time makes the program subject to change." Pearl White, the dashing leading woman of the Pathe Film Company was known widely as the heroine of the movie serial, "The Perils of Pauline." The unimaginative Ballou thought it would be a long time before surgeons could make use of moving picture cameras in operating rooms. He had listened respectfully to Dr. Martin, but his thoughts were concerned with the next meeting in Phil- adelphia in June, at which a convocation for Fellows would be held, and the Clinical Congress in London. The meeting in Philadelphia immediately preceded the annual meeting of the American Medical Association. A special train for doctors from Chicago to Atlantic City was "delayed in starting by several physicians who received emergency calls." The meeting of the Board of Regents held at noon in the Bellevue Stratford Hotel in Philadelphia on June 22, 1914, was not a long one but was preparatory to a meeting of the Fellows of the College scheduled for the afternoon. After considerable discussion by the 11 Regents present, it was agreed to follow Franklin Martin's suggestion that a full-time director of the affairs of the College be obtained. The individual should be a practical man, probably an educator, but not necessarily a medical man. A decision upon the choice of a city for the permanent home of the College could not be made, but the committee was commended for its efforts and asked to report again at the next meeting. President Finney briefed the Regents upon the agenda for the meeting with the Fellows and urged each Re- gent to enter into the meeting with vigor and enthusiasm. George Crile suggested that the best way to raise a million dollar Endowment Fund for the College would be to have the 2,000 Fellows contribute $500 each. Franklin Martin promptly produced for distribution at the meeting a printed card which called for a pledged payment of $500 in five installments, with interest at five per cent, beginning January 1, 1915. The pledge would be void unless the Endowment Fund reached $500,000 by December 1, 1914. Fellowship of Surgeons 149 President Finney presided at the meeting of Fellows which packed the ballroom of the Bellevue Stratford that afternoon. The meeting was called so that the Regents and the Fellows could discuss "man to man" the affairs of the College, said Finney. "The Regents have not forgotten that fact that they are your servants, not your masters, and we are here to give an account of our stewardship." The President reviewed the ideals and purposes of the Col- lege and said that other speakers would recite the hopes and aspirations which guided the Regents. He gave credit to the Re- gents but particularly singled out Franklin Martin, praising him for his great devotion, singleness of purpose and unselfish- ness. He called attention to the fact that money was required to carry on the work of the College. Ochsner, the Treasurer, reported that a balance of $43,891.75 remained from the cash receipts of $58,214.07. He read the itemized expenditures one by one. A savings fund of $40,000, which was drawing three per cent interest, had been created, and the remainder was in a checking account, which was drawing two per cent interest. Ochsner could be long-winded but his description of the work of the Credentials Committee was necessary to dispel the criticisms. It was a detailed account of the procedures employed by the committee which met once a week from seven o'clock until midnight throughout the year. Every application with the report of the local credentials committee and the references was scrutinized. After free discussion, a decision was made upon each application; the applicant was entirely unfit, the references were not clear enough and so required further investigation, or the committee was convinced the applicant was completely qualified. Ochsner believed it was essential to inform the Fellows about the work of the Credentials Committee and spoke at length, "Undoubtedly of the two thousand applications that have not been acted upon as yet, there are many that would have been acted upon favorably had it not been for the fact that one of these elements raised some doubt or question in the mind of 150 Fellowship of Surgeons one of the members of this committee. Not one single nan has been passed so long as there was any doubt in the mind any one of this committee, and I will say not a man on tl committee has given to any name the slightest prejudice. Ever thing is handled entirely upon its merits. . . . The members this committee are men whose names I am not permitted state but whose names every one of you know. . . . "The next thing I will ask you will be to leave everythir personal out of the question. It does not make a bit of differen, what difficulties you have had with this man or that man who application comes into your hands; his credentials should 1 handled fairly. . . . We have found in a number of instant that we could not act favorably simply because there has be( some personal animosity. "12 Edward Martin spoke concerning the requirements for quali cation for Fellowship. "The first tendency, after the formali of organization and the securing of a sufficient number of m( to make it potent, is to make the entrance requirements mo difficult. This we have done, or perhaps are doing; not becau we want to limit the membership but because we want tl young men coming on to be better equipped and traine stronger and more able than ourselves. . . . "We propose the ordinary requirements in regard to ethic standing and in regard to academic education and in regard hospital residentship; and some special study under the char and direction of men of aclmowledged skill and large clinic experience. In addition to this, perhaps the final test, some wo done for the advancement of the general cause of surger

Finally, a report of the man's own work. . . . "13 At last, Finney reminded them of the need for financial su port, "Everyone knows, I am sure, that anything really wor doing, demands of necessity a great deal of energy and a co siderable amount of money, which mean sacrifices." George Crile led off, proposing that each man present pled to give $500. John B. Murphy followed with an oratorical dispE

12 From Minutes of Annual Meeting of Fellows, Philadelphia, June 22, 1914. 12 From Minutes of Annual Meeting of Fellows, Philadelphia, June 22, 1914. Fellowship of Surgeons 151 in his high-pitched voice, interrupted many times by applause. He told them it was fitting that this afternoon, with its privileges, should come to them in the City of Philadelphia where not so many years before a small group of men, bent on a definite purpose and with positive convictions, had founded a model of human liberty. He begged them to remember that the unit around which the medical profession exists is the patient. The purpose of the College was to see that the individual patient received the best service and care that could be given. They were being asked, he said, to contribute money to a permanent fund for the College. Every man there, he was sure, wanted the honor of being one of the founding members and "have his name with this grand body of men, men who are today going to organize the American College of Surgeons on a financial basis that will stand for all time." Evidently, to President Finney, Murphy's speech sounded like a pitchman at a carnival and, perhaps, it embarrassed him. At any rate he interposed some remarks before calling on Charles Mayo, "This was not any shell game at all; and the Regents, when they thought of calling this meeting, had no idea of asking you for money; but when we began to look over the situation it seemed to us that in order to make this College what it ought to be, in other words, to put it in a position to do what you want it to do and what we want it to do, there was one thing absolutely necessary, and that was to have a sufficient endowment; we cannot do the work without it." Finney did not bother to explain the presence of the printed pledge cards which were even then being passed out to the audience. Perhaps he preferred to believe that they simply materialized as the result of the eloquence of the previous speakers. Charles Mayo spoke better in a meeting of the Regents. He was not fluent before a large audience. "We owe it to the profession to do this ourselves; and while this sum of $500 has been set down today in order to give this a start, in order to show the men who have been objectors and there are a few who will not see benefits from this organization for a few years to come, the Board will plan some method by which these men, when 152 Fellowship of Surgeons they come to their right minds, can join us and so do without humiliation to them or to us." Finney closed the speeches in an evangelistic style, "Those who are not here today will be given an opportunity to subscribe to this fund. We hope that each one of you will subscribe and give as liberally as possible. We know every one of you cannot give as much as $500; we want you to give enough to feel it; that is all. That will mean more than $500 for some of you and less for others. We hope it will average $500 and we hope that every individual member will subscribe something. We want to make this as democratic as possible. The good book says that 'Where your treasure is, there will your heart be also.' " The Philadelphia Record on June 23, 1914, headlined a story:

SURGEONS RAISE $100,000 FOR HOME American College Hopes for $1,000,000 — May Erect Building in Washington In an interview, Franklin Martin stated the requirements of the College. He stressed particularly the need for a trained educator of executive ability with a broad vision of the needs of the College who, under the direction of the Board of Regents, could conduct the business of the College and devote his entire time to the office. Other men were needed, he told the reporters. The College would need a surgeon who was actively interested in medical educational problems, especially those relating to the undergraduate medical schools, and who was willing to devote at least one month's time each year to the work of the College. Another surgeon was needed who was interested in the problems of the graduate medical schools; another who was interested in the standardization of hospitals and who could by carefully conducted propaganda bring about an elevation of those standards. Finney went on to Atlantic City where he was to preside as Chairman of the Section on Surgery, General and Abdominal of the American Medical Association. He spoke before a joint meeting of his own Section and the Section on Hospitals upon Fellowship of Surgeons 153 "The Standardization of the Surgeon." Finney was direct and forthright in his speech. Evidently, he had finally been convinced that it was time for plain speaking. After defining a surgeon and discussing the basis of standardization, he ended: 14 . . . Then there is that great and powerful organization, the American Medical Association, of which this Section is one of the component parts. What of it? One has but to refer to the minutes of its past meetings to be struck with the paucity of the recorded efforts made to bring about these universally admitted and much-needed reforms. Why this strange lack of interest on the part of the profession as exhibited in its accredited representative body? What is the reason for this apparent in- difference and inactivity? Is it a spirit of self-complacency? Is it the fear of washing our dirty professional linen in public? Is it a feeling of pessimism that prompts the question "What's the use? You cannot do anything to stop it" Whatever the reason, is it right to sit still and not make at least an earnest effort to right the wrong that every one knows exists? Is it not true that whether we will or no, in this, as in every other respect that concerns his physical or moral welfare, we are "our brother's keeper"? If our professional brother does not know enough to distinguish between a patient who ought to be operated on and one who ought not to be, and if he does not know how to do the operation properly, he ought not to be allowed to operate at all; and if our lay brother does not know enough to distinguish between the properly trained surgeon and the ignoramus, he should be protected from the result of his own ignorance and folly by differentiating for him between the fit and the unfit, and by conferring on the fit some badge of distinction that the public can readily recognize. There is already in existence an organization formed for the very purpose of accomplishing the reforms of which we have been speaking. It is as yet young, but vigorous, virile, democratic, free from all entangling alliances, willing, ready and eager to perform this all-important and so long neglected task. Indeed, it has already made its influence and power felt in certain communities and along certain lines. This is well shown

14 Finney, J. M. T.: The Standardization of the Surgeon. I.A.M.A., 63:17, 1914. 154 Fellowship of Surgeons by the enemies it has made. It can and will accomplish every one of these desired reforms, if only the profession is ready and willing to cooperate with it in its disinterested endeavor to do the work that is so urgently demanded. This is no time for sulking in your tent, just because you feel that the thing is not being done in your way; because the initiative was not taken by this or that organization, or because it was taken by the particular one that did have the courage of its conviction, and did make an effort to correct the evils that every intelligent member of the profession knows to exist. I hold no brief for the American College of Surgeons. It needs none from me; and if it did, this would perhaps not be the proper place or the proper time to submit it. What it has already accomplished speaks louder than any word of mine. Nevertheless, as a member of both organizations and a disinterested well-wisher of both, it may not be out of place at this time and in this presence, to express the hope that the older society may see its way clear in the near future to modify somewhat its apparently studied policy of ignoring in The Journal and its other publications the existence of the younger organization. Would it not rather be the part of wisdom to aid and encourage by the weight of its influence and authority every effort made by any responsible, intelligent body of men directed toward the good of humanity and the uplift of the profession? This is no time for the exhibition of petty personal or professional jealousy or spite. The stake is too great! Rather let us get together like men and brothers, bound in a common cause against a common enemy to benefit humanity, to put down corruption and graft, to cleanse our professional es- cutcheon of the foul blots with which it is stained, to elevate the ideals and the whole tone of the profession, to encourage research and study, to increase the efficiency and to raise the standard of every individual surgeon. It would be shameful to delegate these functions to another, to have them usurped by the state, as will surely be the case through failure on the part of the profession, by reason of professional politics or petty jealousies and misunderstandings, to do what it is clearly its own duty to do, namely, to set up certain high standards of character and attainment which must be rigidly conformed to by every one who would practice surgery. Fellowship of Surgeons 155 Finney had chosen as his text all of the reasons which Frank- lin Martin had presented in Baltimore when he had first gone there to promote interest in a college of surgeons. The convert proved far more eloquent. He had thrown down the gauntlet to those who were guiding the policies of the American Medi- cal Association. However, Finney's words were deliberately misinterpreted or misunderstood. In the discussion which followed his paper, Fin- ney was accused of casting aspersions upon the physicians in the small communities. He reiterated that the honest among these men were just the ones the American College of Surgeons wished to help. He hoped that the dishonest doctors, no matter where they lived, could be put out of business. He emphasized that a differentiation had to be made between the Doctor of Medicine degree, which entitled an individual to pass a state board examination and practice medicine, and a degree which would stamp him as qualified to practice surgery. The initials F.A.C.S. which were to be used after a Fellow's name, were interpreted by many as the granting of a supplementary degree. This was just another point which was erected as an obstacle to thwart the new organization. On June 29, 1914, immediately after the meetings in Philadel- phia and Atlantic City, the newspapers carried headlines about an occurrence the preceding day in Sarajevo, Bosnia.

ASSASSINATES HEIR TO AUSTRIAN THRONE AND CONSORT STUDENT FIRES ON AUTO AFTER DUKE BLOCKS BOMB TRAGEDY WILL BRING PEACE FOR AUSTRIA? FRANCIS FERDINAND HAS BEEN DISTURBING FACTOR OF NATION FEARED AND DISLIKED GAINED ENMITY OF ITALY AND GERMANY: UNFRIENDLY TOWARD UNITED STATES Archduke Francis Ferdinand, heir to the throne of Austria, and his wife, the Duchess of Hohenberg, had been assassinated by Gavrillo Prinzip, a Bosnian Serb terrorist. This brought to a head the conflict between Austria and Serbia. Plans had been made and Ballou had been in London for 156 Fellowship of Surgeons some time arranging for the clinics to be held during the Clinical Congress the week of July 27 to August 1, 1914. This was an ambitious undertaking in a foreign country where such a type of meeting was a complete innovation. Publicity had been obtained and a large attendance of surgeons from the United States and Canada was assured. The June 27, 1914, issue of The Lancet, the old and respected medical journal which represented the British Medical Association, carried an editorial which explained the purposes of the Clinical Congress. In fact, the editorial was critical of scientific congresses which had been held in the past: 15 . . . For highly valuable as the work of scientific congresses has been, and is, in many directions, there can be no doubt that the wheat has been mixed regularly with a great deal of chaff, and that the originality of a large number of the communications to these gatherings is always of a very doubtful character. Sessions are too often taken up with pointless resumes of other people's work; with dissertations upon the absurdity of accepting views or of performing operations that are no longer, as a matter of fact, either accepted or performed; with broadminded disquisitions that propose to remove barriers, but suggest no practical utility for the added territory; and with popularized versions of theories not ripe for the treatment. To the clear intelligence of the American, who has suffered a good deal from the burden of loquacious congresses, the notion came that, if a congress should, first, by its chosen subjects deal only with burning questions, and secondly should be able to bring before its members a number of essentially modern surgeons performing modern operations in an environment typifying modem administration, the members of such a congress would achieve at one and the same time a knowledge of contemporary surgery and a familiarity with hospital methods which could never be gained by the interchange of papers, however informatory in their facts or illuminating in their philosophy . . . . The presidential meeting was held in the Hotel Cecil. After Walter Hines Page, the United States Ambassador to Great

15 Editorial, The Lancet, 186:26, 1914. Fellowship of Surgeons 157 Britain, had welcomed the members, von Eiselsberg of Vienna spoke upon the choice of the operative method for treating ulcers of the stomach. Murphy gave his presidential address on arthrodesis and bone transplantation. Tuffier of Paris discussed transplantation of the ovaries; Robert Jones of Liverpool, Sir John Bland-Sutton, Sir Anthony Bowlby, Charles Mayo, Joseph Bloodgood, James Berry and E. Starr Judd were just a few of the surgeons who were on the program and whose names became internationally known in surgery. The business affairs of the Congress were not neglected. The fourth Congress held in Chicago had shown a profit of over $6,000 so that the deficit of the second and third meetings which had been underwritten could be settled with a comfortable cash balance. Thomas Cullen sent a written report of the activities of the cancer campaign committee and reminded the Regents that the appointment of his committee at the Clinical Congress in New York in 1912 was in reality the seed from which the widespread publicity concerning cancer originated. In the absence of the chairman, Codman of Boston, Allen Kanavel presented the committee's report on the standardization of hospitals. The number and character of the replies which had been received in answer to the committee's recommendations in 1913 left no doubt about an active interest. Due to the efforts of Edward Martin, a general efficiency committee was actively at work surveying all of the hospitals of Philadelphia. In fact, the committee concluded that there was a general desire on the part of hospitals to welcome investigation and standardization. An attempt to have the Carnegie Foundation conduct an investigation had failed. The committee believed that it was outside the province of the Clinical Congress of Surgeons to do more than endeavor to arouse interest and discussion on the question of hospital standardization. However, they strongly urged that some organized body in medicine should take up the work in earnest. They suggested that the American Medical Association, the American College of Surgeons, the American Hospital Association or local agencies, such as those at work in Massachusetts and Philadelphia, should assume the obligation. 158 Fellowship of Surgeons The committee became more specific. It recommended that a formal resolution be sent to the Trustees of the American Medical Association urging the importance of the work and placing upon them the responsibility of actively prosecuting it or at least of formulating and suggesting legislation which would oblige hospitals to adopt some common form of report in order that comparisons in efficiency of the products of surgical treatment might be possible. In the meantime, the committee strongly urged that the better hospitals in the United States set a good example and establish a card catalogue of the end results of treatment, a follow-up system and an efficiency committee composed of members of the medical, nursing and administrative staffs of the hospital. William L. Rodman of Philadelphia, president of the Ameri- can Medical Association, was asked to express the thanks and appreciation of the Clinical Congress of Surgeons to their colleagues of Great Britain. Rodman briefly reviewed the activities of the American Medical Association and the steps which led to the organization of the Clinical Congress and the American College of Surgeons. He said that while the Congress was not an integral part of the Medical Association, what concerned its members could not fail to receive the sympathetic attention of that great body. He expressed the hope that the American Col- lege of Surgeons would follow as closely as possible the vener- able Royal College of Surgeons of England with a "wet sheet, a flowing sea, and a wind that follows fast." The grim visage of war hovered over the meeting. On August 3, 1914, the Chicago Tribune reported that the sailing of the Mauretania was the only word of cheer from Europe. Before many of those in attendance had sailed for home, England declared war on Germany on August 4. Another 24 hours passed before the Tribune headlined on August 5 — ENGLAND AT WAR, BRITISH SHIP SUNK, NAVAL BATTLE IMPENDS. Germany had declared war on France the day before. Several hundred doctors and their wives had planned to go to the continent following the meeting in London. Many of them had return passage on German ships. Each of the German Fellowship of Surgeons 159 steamship lines bad posted "No Ships Sailing" signs. Letters of credit and drafts could not be cashed because Monday, August 3, was a bank holiday. After Franklin Martin had cabled several banks in the United States asking them to extend credit, Thomas Cook & Son agreed to furnish cash for the stranded doctors. A mass meeting of all Americans was called and, accompanied by Dr. Frank Simpson of Pittsburgh, Martin attended to find that about 300 of the group were doctors. It was a large, milling crowd which filled the room at the Waldorf Hotel. Indignation ran high because the United States Ambassador, Mr. Page, was not there to speak and assure them that transportation home would be arranged. The first secretary of the Embassy was present only because Martin and Simpson had asked Mr. Page to come and address the meeting and he had found it inconvenient to do so. Page had promised Martin, however, that he would cable the Secretary of State, William Jennings Bryan, asking that the United States Government send transports to carry its citizens home. When the answer to Mr. Page's cable was read saying that negotiations for passages had been made by the State De- partment with steamship lines, the infuriated Americans calmed down. The meeting of the fifth Clinical Congress in London made it necessary to hold the second convocation of the American College of Surgeons without a co-ordinated scientific meeting. The two organizations still were quite separate financially and administratively. John Finney was the President of the Ameri- can College of Surgeons. Ochsner, Edward Martin, George Brewer and Murphy had been presidents of the Clinical Con- gress of Surgeons. Franklin Martin had already conceived the idea that the Clinical Congress should become the scientific part of the College, but there were stumbling blocks which had to be hurdled before this could be done without stirring up a hornet's nest. There were many who would have objected violently to the junior organization swallowing the senior Clinical Congress. 160 Fellowship of Surgeons A meeting of the Regents in Cleveland, Ohio, on October 18, 1914, resulted in the choice of Washington, D. C., as the location of the annual meeting of the College. After the Secretary had reported upon the status of the Endowment Fund for the permanent home, it was clear that serious steps should be taken to formulate and present to the Fellows a statement of the future needs and aims of the College. It was necessary to prepare them for an appeal for additional financial support. The committee on a permanent home had been unable to make a concrete recommendation as to its location. The action of the Board of Regents regarding the qualifications of applicants for Fellowship was to be presented to the meeting of the Fellows as a report from Edward Martin's committee. Thus, it would become an official action taken by the corporation of Fellows. After a great amount of haggling and an appearance again by the representative of the American Institute of Homeopathy, Dr. James C. Wood of Cleveland, the Regents had adopted a resolution prepared by Matas. This provided that the College would consider eligible for Fellowship all candidates, regardless of whether they were allopaths, homeopaths or eclectics, providing they were able to meet the professional and ethical requirements for Fellowship. It was left to Franklin Martin to make the speech to the Fellows which would prepare them for the financial responsibilities of the Fellowship which had been conferred upon them. Logically, he said, the effect of the requirements for Fellowship which they had just adopted placed an enormous responsibility upon their shoulders. In effect, they, the Fellows of the College, indirectly became the censors of medical schools, hospitals, laboratories, methods of diagnosis and of the care of patients. They would exert a strong influence upon the young surgeon in the making. Martin again expounded his ideas of engaging a trained educator, who with the advice of the Board of Regents and like the president of a university would devote his entire time to the administration of the educational purposes of the College. He Fellowship of Surgeons 161 spoke of obtaining the services of four surgeons "of peculiar adaptability" who would devote at least six weeks of each year to the purposes of urging universities to comply with the standards required by the College for the education of the young surgeon, to convince hospital medical staffs and lay boards to comply with elevated standards, to prepare minimum requirements for surgical laboratory procedures and to look after the legislative measures in which Fellows of the College should be interested. Anticlimactically, Martin said that this excellent plan which already had met with the approval of the Board of Regents had only one serious drawback. There were no funds to put it into effect. Martin was not one to go unprepared, however. He had the answer readily at hand. "To be safe, independent and financially adequate," he said, "commensurate with the personnel, ideals and future possibilities of our organization, we should make provision for an immediate permanent income of $50,000 a year. This administrative fund should come from a permanent endowment fund, invested in perpetuity for the benefit of the College." Subscriptions from 226 Fellows, totaling $113,000 had come from the appeal at the Philadelphia meeting the preceding June. Finney said that not one cent obtained by the subscription plan would be spent in bricks and mortar. The money for the permanent home would be obtained in some other way. Even the Regents had been impressed by Murphy's salesman- ship speech at Philadelphia, and Finney again called upon Murphy's Irish eloquence. He singled out the time and energy put in by Ochsner and Martin saying that their efforts, if sold for another purpose, would represent at least $20,000 a year. He told them they were all blest by having these men in "at the morning of this magnificent organization." "Now, what do you expect for your investment? I won't accept the term `donation.' Such a term does not convey the right idea and has not the right meaning in this case. It is an investment—an investment in your future. It is an investment 162 Fellowship of Surgeons in the future of the surgery of this country. It is, above all, an investment in the security to the people who have confidence in us. That is the prime purpose of this investment; that we will insure and ensure to the people a character of service in the future that they have never had in the past. That is the highest ideal for which a surgeon can work. Will it be a burden on you? No! It cannot be a burden on a body of men, twenty- six hundred or three thousand strong, to pay now $500 for the permanency of this institution. . . ." Dr. Frank D. Gray of Jersey City, New Jersey, gained recognition from the floor and said that he was gratified at the clarification of the point that not one cent of the endowment was to be spent to build an elaborate temple or clubhouse. Support came from an unexpected source when Dr. John Wesley Long of Greensboro, North Carolina, arose to say that he wished "to sound a bugle note of enthusiasm from the rank and file of the Fellows of the College." • • • What does this American College of Surgeons stand for anyway? Does it mean simply that we can throw out our chests and write F.A.C.S. after our names? Is that the idea? Does it mean that we can meet once or twice a year, at some aristocratic hotel in a great center and felicitate ourselves on being members of this exclusive organization? Hardly! I will tell you what it means. "It means that that little half-baked surgeon down there in your country that has got such a narrow conception of his privilege, of the mission of surgery that he slips part of his fee back into the general practitioner's pocket—it means that this fellow has got to be put out of business. It means that that medical journal lying upon your desk in your office now that has questionable, unethical advertisements in it must go into the waste basket and stay there! It means that that little medical college that pays semi-annual dividends and takes it out of the microscope and other laboratory supplies that its students ought to have, has got to close and stay closed! It means more than that. It means that that really great man, little though he be, struggling with unfavorable environment, that you have got Fellowship of Surgeons 163 to put your strong arm around him and say, 'Here, brother, look up and come here and do thus and so and we will do you good." Long then took a "wider conception of the thing" as he put it. Napoleon, China, flaming Europe, trembling dynasties, the blood of untold thousands of innocent men and boys and heroic Belgium all came into his ecstatic peroration. President Finney asked the ushers to pass among them and collect their "auto- graphed cards." He could not stem the tide of oratory, all of which was accompanied by loud applause, until after Dr. George Sterling Ryerson of Toronto, Canada, had proclaimed that the center of medical science and education would be on the North American continent in a short time. The problem of determining accurately the qualifications of applicants for Fellowship was far too complicated to be solved by Ochsner's Credentials Committee in Chicago. He persuaded the Board of Regents to appoint Stokes, Sherman, Bruce, Matas and Crile to act as chairmen of regional credentials committees to represent the east, west, Canada, the south and the central states, respectively. This was the first step in decentralizing the affairs of the young organization and later resulted in the formation of local credentials committees which pass upon the qualifications of applicants for approval by the Board of Re- gents. Regent Stokes exhibited photographs of the proposed site in Washington for the permanent headquarters of the College. Crile emphasized the difficulties Stokes' committee faced when he moved that the President be asked to communicate with the Army and Navy Club to determine if it would be worthwhile to have the Government consider a building worthy of the profession of the United States, a library and museum and a public health service. An adjourned meeting of the Board of Regents was held at 9:00 A.M. on November 16, 1914. Finney was re-elected Presi- dent, and Chipman of Montreal and Matas of New Orleans were elected as Vice-Presidents. Franklin Martin and Ochsner were continued in office. 164 Fellowship of Surgeons It had been provided by the bylaws that the Board of Gover- nors was to elect the officers of the College from among the Fellows. The Board of Governors met briefly at 3:00 that same afternoon, elected Regents and set the date of expiration of their terms. President Finney had appointed a committee of Fellows to nominate the officers, another to nominate Regents and another to nominate Governors at the beginning of the meeting of Fellows. Instructions to the committees were explicit as he announced, "These committees will please assemble here on the left of the platform when their names are called, organize and be ready to make their reports before the close of the meeting." Even the President had caught the swing of getting things done. CHAPTER 5

FIRST convocation of the College in Chicago on November 13, 1913, 1,059 surgeons were admitted to Fel- lowship. There were two convocations in 1914; one in Phila- delphia in June and the other in Washington, D. C., in Novem- ber. The total Fellowship had reached 2,770. With this base, the more stringent requirements for Fellowship became effective. George Crile was enthusiastically hopeful that a pledge to contribute $500 to the Endowment Fund of the College could be obtained from each of these men as a gesture of gratitude for having received Fellowship. One thousand Fellows eventually did contribute $500,000 to the fund which signaled the permanency of the College in the minds of many of its Regents. Franklin Martin's professional office was bursting with the activities of Surgery, Gynecology & Obstetrics, the administrative and financial affairs of the American College of Surgeons and his patients. It became necessary to move from 31 North State Street. Martin chose the recently completed, modern building at 30 North Michigan Avenue for his professional offices and quarters for the journal. He was proud of the fact that there a "practical surgeon," a term of which he was fond, continued to look after the ills of patients and, with his younger associates, edited a surgical journal. There was nothing "academic" about the situation, he said. The official headquarters of the College of Sur- geons were later moved to 25 East Washington Street not far away. There were those individuals who wondered how the three financial operations were kept separated. As is often the case, they immediately answered the question without determining the facts. A whispering campaign, which originated in Chicago and spread rapidly, became exaggerated with each telling. Mar- 166 Fellowship of Surgeons tin, it appeared to some, had a good thing. Finally, the sequence of events which led to the planning of a journal of surgery and to the organization of Clinical Congresses and a College of Surgeons became completely confused. Martin realized that he could not continue to give so much of his time to the affairs of the College and continue his professional practice. At the November 1914 meeting in Washing- ton the Regents had voted to accept reimbursement for actual railroad traveling expenses, but the motion was quite specific in stating, "this is to be interpreted not to include the hotel expenses." Martin had paid all of his expenses incurred in the organization of the Congresses and the College, and each Re- gent had contributed his time and money to help launch the College. Martin had persuaded John Finney to appoint a committee of the Regents to consider a proposal to obtain the services of young men who could grow with the College. It seemed important to him that the first of these should be the man who could direct the educational policies of the College. Martin had his eye on John G. Bowman, president of the State University of Iowa, who, he had heard, was having some difficulty with the state legislators. He liked the spirit which the young fellow, aged 37, showed when he declared that the University was an educational institution and not a political arena. Bowman, a native Iowan, was graduated from the University and received his Master's degree while an instructor in the English department. He had taught at Columbia University for two years and was secretary of the Carnegie Foundation for the Advancement of Teaching for four years. He returned to his alma mater as president in the fall of 1911. Immediately, he was in the midst of a battle of criticism, the opening shot of which had been fired by his retiring predecessor, Dr. George E. MacLean. MacLean exhorted the state board of education to rid the University of the "taint of commercialism" which pervaded the medical school. An editorial in the Journal of the Iowa State Medical Society quoted the Iowa City Daily Press as stating that Dr. MacLean's speech had Fellowship of Surgeons 167 caused a sensation in the University Hospitals and circles of the medical profession in Iowa City. After only a month in the position, Bowman directed a letter to the medical journal's editor. He said that he had read the criticism of the medical college and that after some effort he had not been able to find the authority for the report upon which the criticism was based. "So vital, however, is the question raised by the criticism that we cannot allow it to pass unnoticed," he said. "The University must be above suspicion of bad ethics, and the practice of splitting fees is thoroughly vicious. If the practice of the division of fees ever existed at the University, either in fact or in semblance of fact, that practice is now at an end." Letters from doctors throughout the state charged that there was an abundance of evidence to show that many of the most prominent members of the clinical faculty had been engaged in the business of dividing fees. In his presidential address to the Iowa State Medical Society in 1913, Dr. Vernon L. Treynor of Council Bluffs quoted a letter written to him by Bowman saying that the faculty of the medical school had unanimously taken action condemning fee-splitting and that the state board of education, by a special action, had adopted this attitude of the medical staff as a law applicable throughout the University. However, the members of the board of education were political appointees and the action of the faculty had not been as unanimous as it had appeared. They made their attack upon Bowman with the specific charge that he had insisted that every member of the faculty sign a pledge to abstain from fee- splitting. They claimed this was an invasion of their rights as citizens. Bowman's entire term of office as president of the State Uni- versity was occupied with this struggle among the board, individuals on the faculty of the medical school and himself. It was quite clear that certain interests entrenched at the University and supported by members of the board of education had brought about an intolerable situation for Bowman. The Carnegie Foundation annual report in 1914 stated that the 168 Fellowship of Surgeons legislature had been unable to make up a board to conduct educational matters without being influenced by political considerations—the criticism of educational policies was severe. The offer to become Director of the American College of Sur- geons came as a relief. Franklin Martin presented Bowman's name to the Regents at their meeting in Chicago on February 6, 1915, for the position of Director at a salary of $6,000 a year. The majority of the Regents had met the young man and he was engaged with the understanding that he should begin his work immediately. Commercialism in surgery in Iowa had plagued the Regents from the beginning. J. B. Murphy and Charles Mayo supported a motion which directed that the first duty of the new Director should be a careful investigation of the Iowa situation by personal visits to doctors throughout the state. Fee-splitting was undoubtedly not a new problem to Bowman. Franklin Martin was annoyed at the thought that perhaps some of the Regents were favorably impressed only because of Bowman's experience in fighting this unethical practice. He wanted Bowman to give his energy and effort to the problems of educating and training surgeons and to making hospitals better places for the sick with accurate records of illness and operations. Fee-splitting would disappear eventually, he hoped, as the surgeon became better educated. A war was being fought but the United States remained an interested bystander until the newspapers headlined the news of the sinking of the Lusitania, a Cunard liner which carried many United States citizens. A German submarine, the U-20 under the command of Captain Schweiger, torpedoed the large passenger ship off the Head of Kinsale, Ireland, and she sank in 15 minutes with a loss of 1,400 lives. President Wilson was shocked and the Capitol was tense with the grave crisis which had arisen. The German Embassy had warned United States citizens not to sail. The Government protested in strong language to Germany. Those who were wise predicted that this was the incident which would bring about the gradual entrance of the United States into the conflict. Fellowship of Surgeons 169 It was, indeed, gradual; it would take a long time to condition the people to the idea of preparing for a war to be fought to save democracy when their own homes were safe and comfortable. It would take a long time to mobilize industry and labor. Doctors would not readily accept the idea that they would have to leave their practice and put on an uncomfortable cap and bulky puttees to care for the wounded. In this atmosphere of mounting uncertainty, there was no real interference with the progress of the affairs of the American College of Surgeons. Director Bowman spoke for the first time at a rump session of the Fellows of the College held in San Francisco on June 21, 1915, during the meeting of the American Medical Association. Harry Sherman, who by this time had become a dedicated Re- gent, presided. The Fellows were enthusiastically vocal in expressing their thoughts about fee-splitting, methods of examination which would keep out the untrained and unqualified, and pleas for contributions to the Endowment Fund. Sherman was a patient presiding officer and the speeches were long, but it was a spontaneous expression of what representative surgeons from all over the United States thought about the College. After they were admitted to Fellowship, they were particularly concerned that entrance to the select group should not be easily acquired. Already, some who had been most critical of the original founders because of their selectivity were far more conservative. Bowman encouraged this spirit. He compared the Fellowship with a Master's degree obtained by additional work in the graduate school of a university. They were scholars in a select group, so they should represent a selected group of surgeons. The new Director warned them not to be impatient with the course of events. It would be absolutely necessary to have an Endowment Fund from which activities of the College could be financed. Publicity was needed so that the ideals and accomplishments of the College could be brought before the public. This should be planned like a good advertising campaign so that it would have a cumulative effect upon the public's mind. Ten 170 Fellowship of Surgeons years, Bowman said, would be required before the first effects of the College policies could be felt. In Boston on October 29, 1915, Director Bowman again appeared before a meeting of the Fellows. This time he was presented formally by President Finney. Bowman had not been a part of the original organization. However, he was willing to carry the banner in educating the public as to the aims of the College. This would befit his educational background. He reminded the Fellows that after three years, $400,000 was in the Endowment Fund, pledged and donated almost entirely by them. A total of 7,500 applications for Fellowship had been received and processed. Including the 1915 convocation, 3,254 surgeons had been admitted to Fellowship. 1 Good surgeons were still on the outside, he told them, and undoubtedly men were on the inside who should not be there. The idea that future admissions would be by examination was a good one, but it was a difficult problem to solve. At that moment, no one had the correct answer. The information obtained from patients' histories submitted for qualification was not enough, Bowman said. The applicant's standing in his community and among his colleagues was important. Bowman then appropriated the plan originally suggested by Joseph C. Bloodgood of Baltimore and proposed that the organization, aims, standards and ideals of the College of Sur- geons be put in the hands of every senior medical student. If they expected to be surgeons, they should be told early in their career about what the College stood for and what it proposed to do. This was the way to build a strong future for the organization. Bowman anticipated no difficulty in obtaining the co-operation of the faculties of medical schools in allowing a great surgical organization to make such a presentation to its students. It did not occur to him that the American Medical Association would ask for similar time before the students and this could be carried to an absurdity. Bowman met opposition from the Fellows when he spent a

1 In 1913, 1,059 Fellows were admitted; in 1914, 1,711; in 1915, 484; in 1916, 228; in 1917, 313; in 1918, 325; and in 1919, 213. Fellowship of Surgeons 171 great deal of time and effort to obtain a beautifully engraved Fellowship certificate at no expense to the College treasury. The Fellows were not exactly enthusiastic in their response to his request for $15.00 to pay for their copy. He also had to disabuse their minds of the impression that it was nothing more than a fee-splitting pledge. To abstain from division of fees was a part of the Fellowship pledge, he said, and the piece of parchment was colorful and they could be proud to hang it in their office. Finally, he told them that he was heartily tired of the topic of fee-splitting, after having been mixed up with it in his capacity as president of the State University of Iowa. Printed material which had been sent to the Fellows by his office had offended some of them. They thought it had been sent because they were believed to be guilty. Others thought it was in bad taste to talk about the subject of fee-splitting at all. It was said that the practice didn't exist in some communities. Perhaps that was true, Bowman stated, but he had not found such a city. It would take patience and he was a bit impatient with the Fellow who wrote making charges which he wouldn't, or couldn't, substantiate with evidence. Given the evidence, the Regents would act, he assured them. Bowman made a good impression in his opening speech. He ended by saying, "I do not want you to think that the College is going to impress itself on the public all at once, and hold you up as a shining example of its membership. Not a bit of it. It will never do that. With all due modesty, a man has got to perform his part and create the impression that this organization stands for the kind of show in which the patient always is the star." Bowman had neglected to speak about an important matter. President Finney said he would, therefore, call upon Charles H. Mayo who was fully informed about the subject. Dr. Charlie arrived at his text by saying that year after year at practically every meeting of medical men in the country, a committee was appointed to consider the question of fee-splitting and professional honesty. These committees brought in their reports and 172 Fellowship of Surgeons the committees were continued. Nothing real had ever been done until the question of fee-splitting was taken up by the College. Already, it had become apparent, he said, that the actions of the Regents have had "a most marked effect on the honor of the profession in this country." "Now," Mayo continued, "the question of hospital efficiency comes up. We tell these younger men who are to join this association that they shall present a record of fifty cases on which they have operated. No one appreciates more than the surgeon, the necessity of hospitals and their efficiency, yet in this entire country there is no association of hospitals. There is not even a minimum of hospital standards. . . . This matter is under discussion by the legislatures of various states; to have private as well as the public hospital under the supervision of the state to see that they conform to rules for the benefit of the patients. Inasmuch as it stands for professional honesty, we want a standard of hospital efficiency so that the hospital itself may be standardized. "In spite of all the meetings that have been held—and there has hardly been an organization in the last four years that has not appointed a committee to talk about hospital efficiency —nothing has been accomplished in this direction, and nothing can be accomplished unless an organization of this kind takes cognizance of it. "Therefore, at the meeting of the Regents held today a sum not to exceed $500.00 was appropriated for the actual work to be done. . . . We will establish as soon as possible the minimum hospital efficiency record. That does not mean that we must come down to that record, because that minimum is only about one-half of what we want in our hospitals. It is being carried out in Massachusetts, and in fact the greatest stimulus has come from accomplishments in Boston, and I give great credit to Dr. Ernest Amory Codman for his pioneer work. While the work will be under the direction of our Director, Mr. Bowman, Dr. Codman will be on the committee." 2 Attempts to obtain money from foundations or other sources

2 Minutes of Annual Meeting of Fellows, Boston, October 29, 1915. Fellowship of Surgeons 173 outside the treasury of the College had failed. Five hundred dollars was a modest appropriation but it was the step which was to bring the recommendation of Codman's committee on hospital standardization to the starting line. This had been one of the primary educational projects fostered by the College and it was assumed that hospitals would enter into the program more energetically than they had. It had not been anticipated that this effort had to be prosecuted vigorously by the College, or its own program for the qualifications of its applicants would fail. This had become apparent when the applicants, in lieu of a practical examination, began to submit their case records of major operations performed. The deficiencies were glaring both on the side of the surgeon and the hospital. The Regents came to appreciate that the particular training ground for the surgeon is the hospital. The obligation to know what this training ground is and what kind of a standard should be held up as the proper training of a surgeon in a hospital was forced upon them. It became evident that it would be quite impossible to separate the training of the surgeon in a hospital from the hospital's program. One could not say that at this point the training of the surgeon begins and that at that point it ends. The training of the physician is also largely the training of the surgeon. The problem was easily reduced to a simple question—what is the proper care of sick people? Specific divisions in every hospital could be investigated to obtain accurate data from which to point the way of progress. How complete were patients' histories? Were the findings of surgical operations recorded immediately after the operation? Were the records accessible for study and future guidance? Were the end results of operations followed with conscientious common sense? Were the summaries of those operative results made public as evidence of the competence of the physicians and surgeons practicing in the hospital? What were the conditions of the hospital laboratories? Important elements in the training of the surgeon should be that he know how to use the laboratory and that he form the habit of using its facilities. What laboratory facilities should a 174 Fellowship of Surgeons hospital of a given number of beds reasonably be expected to provide? The laboratory findings upon each patient should be made an integral part of the case history. The pathologist should report his exact findings as a part of that record. Do the superintendent and the trustees, who are responsible for the government and the administration of the hospital, take pains to assure themselves that the work of the laboratory is competent and that reports of the findings are set clown fearlessly? The last question led naturally to the entire problem of hospital administration. What should be the relation of the board of trustees to the medical staff and to the hospital superintendent? The business of the superintendent is to carry out the directions of the board of trustees and he should be told by them what kind of a staff is privileged to practice medicine and surgery in the hospital. The trustees of all hospitals, the College said, should be able to guarantee honestly to their communities competent medical and surgical service. These were the principles which the American College of Surgeons sought to bring about and it proposed to deal with them "in no uncertain or half- hearted fashion." Doctors who wished to apply for Fellowship in the College complained bitterly to their hospitals when their case records were unacceptable. The hospital administrative group quickly realized that they must act. They must be concerned with more than economy and efficiency in hospital management, construction problems, systems of accounting and lobbying efforts to influence national and state legislation. They appealed to the College for advice as to how they could help their doctors furnish acceptable evidence of the character of their surgical work. The College, through Codman's committee, had organized many subcommittees to formulate systems of record blanks which were made available to all hospitals and were freely copied and modified. Fellows of the College urged the Regents to furnish definite detailed instructions which hospitals could follow in improving their x-ray, laboratory and pathology departments. Director Bowman spoke to many groups of hospital Fellowship of Surgeons 175 administrators over the country explaining that the success of the College and of their own organization were closely related. It was soon apparent that as the requests for advice poured into the offices of the College, a grave responsibility was being forced upon the Regents. Although the committee on the standardization of hospitals had recommended the American Medical Association as the proper body to supervise the elevation of hospital standards, that organization had taken no action. After a full discussion, the Regents again decided to recommend to the Chairman of the Council on Medical Education, Dr. Arthur Dean Bevan of Chicago, that this activity properly should come under the wing of the American Medical Association. In reply, Bevan spoke of the tremendous expense involved in such an undertaking and stated that the matter had been discussed by the Board of Trustees of the Association. They had decided not to accept the responsibility of the task. Bevan was asked if there would be any objection to the American College of Surgeons doing the work and he replied in the negative. This left the College free to undertake the project but quite definitely placed an important financial obligation upon its shoulders. It was clear that the allocation of $500 to the hospital standardization program proposed by Dr. Mayo would be but a drop in the bucket, if the program of popularizing the assumption of authority in hospital requirements by the College was to become workable. The Regents had agreed that a subscription of $500, by a Fellow, toward the Endowment Fund would cancel the initial Fellowship fee. A large number had paid the Fellowship fee and also made a subscription. Consequently, $50,000 was transferred from the operating funds of the College to the Endow- ment Fund. After considerable debate, the Fellowship admission fee was raised to $200, except for those whose applications had been received before November 1, 1914, when the admission fee was $50. The payment of $100 was required within . 30 days after notification of acceptance to Fellowship and the balance could be paid at the rate of $25 per year for four 176 Fellowship of Surgeons years. At the same meeting of the Regents, it was decided to open the ranks of Fellowship to surgeons in South America. It had cost the College $28,378.26 to carry on its affairs between November 1, 1914, and September 30, 1915. The assumption of the hospital standardization program also entailed a large financial obligation which the Regents had to plan to meet. The question of the location of a permanent home for the College had again been postponed mainly because of the lack of funds. Finney, Franklin Martin and Ochsner had been re-elected to their respective offices. Ochsner, the Treasurer, proposed that any Fellow who had not paid $500 into the Endowment Fund be charged annual dues of $25, while he was in active practice, until the sum of $500 had been paid. Ochsner and many other Regents were finally willing to assess annual dues, to which they had been opposed in the beginning, arguing that one should not be required to pay dues to a College. The assessment of annual dues smacked of just another surgical society. The financial strain on the College was relieved on January 27, 1916, when the Carnegie Foundation made a gift of $30,000 to be used in the hospital standardization program. Bowman had been secretary of the Foundation and was a close personal friend of its president, Henry S. Pritchett. Bowman had been responsible for enlisting the interest of the Founda- tion, which previously had refused its help for this same purpose. Now it became possible to proceed with some vigor. At Bowman's insistence, it was decided to propose only a minimum standard for hospitals to meet. This would contain the fundamental requirements essential in every institution for the care of the sick. Bowman argued that a maximum standard would be burdened by unessential details which would militate against its acceptance by both the public and the hospitals. The College had to accept the responsibility of furnishing a minimum standard which would include all branches of medicine in a general hospital. It would require a great deal of work, advice and editing to write a one-page explanation of the requirements for a minimum standard. Fellowship of Surgeons 177 Following the sinking of the Lusitania, a frightening succession of world events occurred. Italy declared war against Aus- tria and Turkey; Great Britain declared war against Bulgaria, as did Serbia, France, Italy and Russia in rapid succession. The United States Government was denounced in the German Reichstag and it appeared that the holocaust would become world-wide. Italy finally declared war against Germany and Romania against Austria on August 27, 1916. Romania thus gained the doubtful distinction of being the last country in Europe to participate. Just 16 days previously, on August 11, in the Grand Hotel at Mackinac Island, Michigan, John B. Murphy had died following a coronary occlusion. It was a blow to Franidin Martin, who for so long had admired Murphy's aggressive ability and eloquence. He had been encouraged by Murphy as he unfolded his imaginative schemes. Murphy had supported him faithfully and loyally in establishing Surgery, Gynecology & Obstetrics, in organizing the Clinical Congress of Surgeons of North Amer- ica and in forming the College of Surgeons. Martin had found him modest in his personal ambitions; in fact, he had been admonished by Murphy to turn to other men for the presidency of the Clinical Congress and the College of Surgeons. Martin's friendship and loyalty to Murphy had always been and was to remain unwavering. In fact, Martin's defense against the critics of Murphy after his death became an aggressive, active offense. Prior to Murphy's death, Franklin Martin had been firm in his opinion that the permanent home of the American College of Surgeons should be located in Washington, D. C., or any city other than Chicago. He believed that the American Medical Association headquarters located in Chicago would be a detri- ment to the future of the College. The Regents' committee on the location of the permanent home had been working faithfully but had been unable to come to a conclusion. Some of the Fellows had complained to President Finney about holding meetings of the College of Surgeons in conjunction with the meetings of other organizations. "Isn't the College big enough to stand by itselfr they asked. 178 Fellowship of Surgeons Finney explained to them that the meetings had been scheduled in cities where other associations were in session to conserve traveling expenses on the part of the Fellows and to save their time. The location and establishment of a permanent home, Finney said, might well be the deciding factor in changing the policy. The Regents were committed to the policy of not spending any of the money which they were working so hard at raising for "bricks and mortar." At the meeting of the Fellows in Boston, Charles F. Stokes reported for the committee on the permanent home, saying that the interest of the Fellows in establishing a permanent home had made it become an acute problem. The members of the committee were in favor of Washington, D. C., but they proposed to submit the question to all of the Fellows so they could express their own preference. Stokes pointed out that it was a matter of finding enough money to invest in a permanent home and said that it was barely possible that some good friend might come forward with a liberal donation. Finney said there were certain intimations, not so very definite he hurried on to state, that if they were not in too big a hurry to buy a home, somebody might give them one. He then read an excerpt, for their encouragement, from a letter written by the "wife of a surgeon not long deceased who ex- presses her willingness and desire to create some sort of a memorial for her husband under the control of the American College of Surgeons." Franklin Martin had been able to persuade Mrs. John B. Murphy to think seriously of such a memorial to her husband. However, her letter referred to research work rather than a building.8 It was becoming more and more certain that the location of the permanent home would be in that city in which the largest contribution to the financing of the home could be obtained. At the moment, Chicago was coming up fast from the pack.

8 The excerpt which Finney read was: "If your noble organization should desire to found research work along the lines that my husband was so wonderfully devoted to, let me say that it would be my humble pleasure to contribute in his name to such work to the amount that I would be able." Fellowship of Surgeons 179 Ochsner assured the Fellows that the College was receiving an average of 4.65 per cent interest on its invested money. As always, the Treasurer reported upon the auditor's examination of the income and expenditures. There were always some who wondered where all the money was going. As the meeting neared its end, Edward Martin, chairman of the endowment committee took the floor. Pledge cards were passed out. The chairman and others from the Regents exhorted them to contribute: Gentlemen, we are within $15,000 of the sum we need to insure our money. Now, tonight, you are justifying yourselves first, you are justifying your profession next. You are expressing your belief in your Board of Regents, you are expressing your belief in what seems to us to be a splendid endorsement of the real Dr. Martin. We want 30 more men, gentlemen. Are you going to let it drop? Who will help us? Now we want 27 more. Now twenty-six more. . . . "Ned" Martin proved he was a real spellbinder. Franklin Martin was shrewd enough to understand that the prospects for raising money from the Fellows to finance the purchase or construction of a permanent home for the College were indeed poor. The death of his friend, Murphy, provided an opportunity to approach citizens in Chicago to contribute to a memorial associated with the College, particularly since Mrs. Murphy had expressed her desire to have such a memorial. It would be necessary to change the direction of her wishes, or perhaps to point out that research work required a building, whether the research was experimental or clinical. He went to his friend, Ted Donnelley, who had helped him with the surgical journal, to Edward Hurley, to Dr. Norman Bridge, a physician friend of Murphy's and a close friend of Edward Doheny, the rich oil man, and to other citizens of Chicago, including Fellows of the College, and talked about the project with them. Sufficiently encouraged by their responses, it was planned to form The John B. Murphy Memorial Association, a separate organization for the single purpose of raising money to create 180 Fellowship of Surgeons a memorial for John B. Murphy. When that task had been accomplished, the association would be dissolved by the act of transferring the money by gift to the recipient. Contribution cards were printed which assured the donor that a memorial to John B. Murphy would be created. It was but a short time until approximately $300,000 had been pledged, of which Mrs. Murphy and her three daughters agreed to contribute $100,000. A special meeting of the Board of Regents was called in New York on September 30, 1916. The purpose of the meeting was to consider the tender of a gift of money to the American College of Surgeons from The John B. Murphy Memorial As- sociation. This gift was to assume the form of a memorial building to be used as the executive headquarters of the College and and to be located in Chicago. Franklin Martin explained to the Regents in detail how he had enlisted Mrs. Murphy's interest and that of other citizens of Chicago who had been Murphy's patients or students. It had not been easy to convince Mrs. Murphy that a building was the proper memorial for her husband. He assured the Regents that he was quite confident that another $200,000 could be obtained and that for half a million the College could have a home. He had become convinced, as the College had grown and prospered, that they need not fear because the American Medical Association headquarters were also located in Chicago. In typical fashion, he had come prepared with a plan of action. He proposed that the question of the permanent location of the College be submitted to a vote of the Fellows and that the Regents authorize a contract in acceptance of the proposed gift, provided that Chicago be approved by the Fellows as the location of the College. Mayo and Crile promptly made and seconded a motion to carry out this proposal. It would be necessary in submitting the question to a vote of the Fellows for the Regents to make a statement of their own analysis of the problem. The question, it would be explained, had arisen as an emergency at the time because of the tender of a gift of approximately $300,000 Fellowship of Surgeons 181 from The John B. Murphy Memorial Association. The Regents had voted to ask the judgment of the Fellows as to the most suitable permanent location for the College and this was now being done. If accepted, the gift would take the form of a memorial building to be located in Chicago. The analysis of the Regents, a very persuasive document, was written by Franklin Martin. . . . The desire of citizens, especially of Chicago, and of the profession of medicine throughout this continent, that a suitable memorial be built to the memory of the late Dr. John B. Murphy is without precedent. This desire found quick expression in a corporation known as The John B. Murphy Memorial Association, which pledged itself to raise from $300,000 to $500,000 for an appropriate memorial. Naturally, many established institutions in and about Chicago wish to secure this fund and are making attractive offers in order to do so. The widow of the late surgeon and his most intimate friends, however, are convinced that the proposed memorial could most properly be transferred as a gift to the American College of Surgeons, first, because the College is a permanent organization; and second, because it is a living power to advance those principles in the profession which Dr. Murphy loved and labored for through his life. The fact is that, outside of his immediate family the College was most near Dr. Murphy's heart since its inception. His interest in it exceeded his enthusiastic expressions on its behalf. He gave to the College unsparingly of his time, money and influence. . . . The recommendation of the Regents to the Fellows were given seriatim and without reserve.. The College was recognized, they wrote, by intelligent folk as a guarantee of honesty and of competence in surgery. Its work was exceeding in magnitude all previous conceptions. The necessity for a great administrative building had gone beyond debate. The responsibility of the College in examining the tons of records which would be submitted as evidence of fitness for Fellowship could be carried out only by having additional space. Adequate pub- ° See Appendix, Chapter 5:1. 182 Fellowship of Surgeons licity must be managed to convey the meaning of the Col- lege within the social and economic fabric of the country. A beautiful assembly hall for the Fellows in the permanent home was highly desirable. Chicago was geographically well located and easily reached. It was to be hoped that a great medical museum with facilities for research would be erected on one side of the administrative building and a great medical library on the other. With- out any doubt, these would come later as gifts to the College, if it reasonably fulfilled its service to the public and to the profession. Distinguished merit among the Fellows of the Col- lege could be memorialized in the future by appropriate additions to the home of the College. The analysis emphasized strongly that it had become a thoroughly established custom among American and English colleges and universities to accept libraries, science and other buildings in the memory of men or women, who during their lives were interested in the welfare of the institution. The Hunterian Museum of the Royal College of Surgeons of Eng- land and the Harper Memorial Library at the University of Chicago were cited as examples. Therefore, no reasonable ground for objection could be found to the acceptance of a proposed building such as The John B. Murphy Memorial Hall of the American College of Surgeons. Martin and the other Regents knew that there would be objections to memorializing Murphy's name and to the location of the home in Chicago. Murphy, himself, had refused Martin's insistent demands that he be the first President of the Clinical Congress and of the new College because he was a highly controversial figure in the profession. However, there was little reason to expect that the vote of the Fellows could disapprove such a weighted proposal. Many Fellows regarded the submission of the proposition to a vote of the Fellows as hypocritical because it carried such an important financial gift with it. They all wanted a permanent home of which they could boast and be proud. They were hesitant about contributing to a building fund and constantly wished to be assured that their subscrip- Fellowship of Surgeons 183 tions would never be used for "bricks and mortar." They asked if the Regents were becoming highhanded. The Regents passed an appropriate resolution authorizing the Secretary to execute a proper contract with the Murphy Memo- rial Association on behalf of the College, providing that a majority of the Fellows voting favored Chicago as the permanent home of the College. Their gratitude and appreciation were formally expressed to the Association.° The contract which was finally drawn up provided that the American College of Surgeons and the Murphy Memorial As- sociation agreed to co-operate in securing a fund of at least $500,000 which should be used only for the erection of a building as a memorial to John B. Murphy, for the purchase of a suitable site and for the payment of incidental expenses.** The building was to be named after Murphy and so designated for all time. Later, the pledge cards specified that the building was to be a memorial to Murphy in perpetuity. At the October 1916 Regents' meeting in Philadelphia, the e vote of the Fellows upon the location of the College was recorded as 1,550 for Chicago and 315 votes divided among eight other cities.4 A communication from the Fellows residing in . New York City, presented by Dr. John B. Walker, requested that the question of the location of the College's permanent home be discussed at the annual meeting of the Fellows. After considerable discussion among the Regents, the vote of the Fellows favoring Chicago was accepted as final by the Board, providing of course that the Murphy Memorial Association concluded its tentative agreement to donate funds for the erection of an administrative building for the College. However, Finney later made an explanation at the regular meeting of the Fellows. The previous year in Boston he had said that no final report upon the location of the permanent home would be made until every Fellow had the opportunity to express his preference. He had received a large number of

• See Appendix, Chapter 5:2. " See Appendix, Chapter 5:3. 4 This vote had been conducted by mail. 184 Fellowship of Surgeons letters protesting the precipitate action. He said that the word "recommend" used in the communication from the Regents had been poorly chosen. It had not been used with the idea of forcing agreement from the Fellows but simply to let them know the opinion of the Board of Regents. Finney recognized, he said, that there might be some academic objection to attaching an individual's name to a building of such an organization as the College. He challenged them to say that a name which stood for so much in American surgery as that of John B. Murphy could be a handicap to any organization. He went on to say that the Regents had to act quickly because the proposition had just been presented. They did not wish it to be delayed for a year because the offer would not be open for any great length of time. A firm of certified public accountants had tabulated all the replies received from the Fellows. Regent Brewer of New York reported that the location of the permanent home of the College in Chicago had been decided by the vote of the Fellows in which the Board of Regents concurred. Many other matters of business came before the Regents. Charges were being made against men who had been admitted to Fellowship, particularly upon the grounds of unethical conduct. The Regents had said repeatedly that they would take action if the charges were supported by evidence upon which they could act with moral and legal integrity. Seven Fellows were expelled at the meeting held in Philadelphia on October 27, 1916. The Regents were determined to demonstrate their own integrity by reading the names of the disciplined members before the meeting of the Fellows. This was done upon one occasion before cooler heads intervened. Thereafter, suspensions and ex- pulsions were treated in a purely statistical manner. At the same meeting, two Fellows, who had been found guilty by the Regents of continuing the practice of fee-splitting, were allowed to resign. It was this decision by the Regents to discipline its Fellows quietly that led to the many unfounded accusations Fellowship of Surgeons 185 later on that the College never took action against its Fellows because it was always campaigning for members. Much to the surprise of many of the Regents who had been reluctant to use the word "dues" in connection with Fellowship in a College, the Fellows were strongly in favor of requiring the payment of dues. It was true that many of the Fellows had contributed to the Endowment and Building Funds and they saw no reason why the large group of non-contributors should not do their share in supporting the financial responsibilities which the College had assumed. Dues were set at $25 per year, except for those Fellows who had already subscribed $500. This annual payment was to continue until a total of $500 had been paid. No dues would be charged if the Fellow had reached the age of 65 years, or if he had retired from his professional practice. The Regents were happy to receive word from the American Hospital Association that on September 26, 1916, it had taken action to co-operate with the College in the movement initiated to raise the standards of hospitals. Winford Smith, director of the Johns Hopkins Hospital in Baltimore, had been appointed to represent the Hospital Association. No financial help accompanied the action but at least it gained the co-operation of hospital administrators without which the Regents knew their task could be made difficult. John Finney had served as President of the College and had acted as Chairman of the Board of Regents since the beginning. He had been the focus around whom the supporters and detractors of the new organization had gathered. The fact that he had slowly been imbued with admiration, respect and love for the purposes and ideals of the new association of surgeons offered mute evidence to many doubters that the goals to be accomplished were well worth the effort. George Crile was elected to succeed Finney as President and Chairman of the Board of Regents. He was more of an extrovert and had a voluble, contagious enthusiasm which Finney lacked. Prior to Crile's election as President, Edward C. Kendall, a biochemist at the Mayo Clinic, had isolated the active constitu- 186 Fellowship of Surgeons ent of the thyroid gland. He wished to protect his discovery from exploitation by private manufacturers and dealers. Ken- dall applied for letters patent upon the substance and upon their receipt, he assigned all right, privilege and patent to the American College of Surgeons, as trustee, to do with as it deemed fit for the benefit of the medical profession and the public.° In turn, the American College of Surgeons was asked to agree to control the production and the purity of the substance. If any profit should be derived from its sale and distribution, such money was to be used for medical research. This act upon the part of Kendall was without any doubt initiated by the brothers Mayo. The substance—thyroxin—was to revolutionize the treatment of goiter, particularly its toxic manifestations, so prevalent in the Great Lakes region of the United States. The Regents authorized the President, the immediate past President, the General Secretary and the Director to enter into such agreements with manufacturers as might be necessary to produce and sell thyroxin and to protect the patent. Previously, a resolution passed by the House of Delegates authorized the American Medical Association to accept and administer the patents upon thyroxin which Dr. Kendall had offered to that Association. Later, the patent was returned to Kendall with the explanation that to regulate the production and purity of the substance would be completely outside the function of that organization. 5 Obviously, the Regents of the College could visualize a considerable income which could be used for the educational purposes and research they were planning. It is quite doubtful that all of the Regents knew that it had been offered elsewhere and turned back. The question does not seem to have been raised as to why, since Dr. Kendall was on the faculty of the University of Minnesota and was carrying on his work under the auspices of the University and the Mayo Foundation in his

• See Appendix, Chapter 5:4. 5 Fishbein, Morris: A History of the American Medical Association. Philadelphia, W. B. Saunders Company, 1947, p. 294. Fellowship of Surgeons 187 laboratory in Rochester, these matters were not left immediately in the hands of the institution in which the work was being performed. Satisfactory conditions could not be agreed upon between the House of Delegates of the American Medical Association and the legal counsel representing Kendall and William Mayo. By making an outright gift to the American College of Surgeons, Mayo hoped that it would set a precedent and quiet the critical opposition which had arisen accusing the Mayo Clinic of making money from a necessary therapeutic agent. However, it soon became apparent that the American College of Surgeons was not in a position to manage the patent and the arrangement was terminated with mutual satisfaction and without financial benefit to the College. The patent was then given to the University of Minnesota, which licensed E. R. Squibb & Sons to manufacture and sell thyroxin. During the life of the patent, the University of Minnesota received a total of about $60,000 which was held in "The Thyroxin Fund."6 It had become more and more evident that the Clinical Con- gress of Surgeons of North America should become a part of the American College of Surgeons. Its scientific meetings could be absorbed into the educational activities of the College naturally and easily. Administratively, the Clinical Congress had been completely separate. Though it has been assumed that its earliest Presidents were also Presidents of the College, this is not true. There were some misgivings about joining the Congress to the College. At the outset, only the subscribers to Surgery, Gynecology & Obstetrics had been invited to attend the first Congress. This list was later enlarged and a registration fee was charged. Rumblings and criticisms had been heard because all of those who had attended the Clinical Congresses had not been invited to become Founder Fellows of the new College. The campaigns to raise the standards of hospitals and to publicize the profession's attempt to fight cancer had originated

8 Personal communication from Dr. Edward C. Kendall, September 4, 1958. 188 Fellowship of Surgeons within the Clinical Congress meetings. These were original projects which were jealously guarded. On June 12, 1916, at a meeting of the Regents in Detroit, a resolution was adopted upon the motion of George W. Crile and Rudolph Matas, to appoint a committee consisting of the ex-Presidents of the Clinical Congress of Surgeons of North America (Edward Martin, Albert J. Ochsner, George E. Brewer, John B. Murphy and Charles H. Mayo) and the President of the College ( John M. T. Finney) to confer with a committee to be named by the Regents to consider the advisability of consolidating the two organizations.° This appeared to be a heavy handed and cumbersome approach to accomplish a logical union between two organizations which had been conceived in the mind of one man but it did have the appearance of a democratic method. In January of 1917, the committee submitted a tentative plan of affiliation. This provided that the annual meeting of the Clinical Congress of Surgeons of North America and the convocation of the American College of Surgeons be held each year during the same period and in the same city. The clinical meeting would be named the Clinical Congress of the American College of Surgeons. Membership in future Clinical Congresses would consist of those who made an advance registration each year to the limit of attendance agreed upon by the executive committee of the Congress and the local committee upon arrangements from an invitation list to be provided. This invitation list would consist of the Fellows of the American College of Surgeons and all members of the Clinical Congress, as fixed by the existing bylaws, who would be required to sign a declaration that they would not practice the division of fees under any guise. The loose employment of the word "membership" was again causing difficulty. Many of those doctors who had attended the previous Clinical Congresses were not admitted to Fellowship in the College. Yet, they considered themselves members of the Clinical Congress, an organization which was being merged • See Appendix, Chapter 5:5. Fellowship of Surgeons 189 with the College. Furthermore, it was difficult to state categorically that these "unwanteds" were not qualified by training to become Fellows. Some of them had more training and experience than those who had become Fellows. The test of whether or not they would willingly sign an oath that they would never split fees could be used as a sieve. It would become a question of debate for many years in the future of just how sincere some men were when they signed the declaration. On October 19, 1917, one year following the first proposal of amalgamation, the merger was consummated by the men who had been most active in the affairs of both organisations. They removed one hat, put on another, replaced the first and, by proper resolutions duly recorded, effected a step about which the timid among them were fearful of an avalanche of criticism. In order that the problems involved in the affiliation could be discussed in a joint session of the committee of the Clinical Congress and that of the Regents, the meeting of the latter group was suspended. A. J. Ochsner became chairman of the joint session. Ochsner had been the first President of the Clinical Congress of Surgeons and was presently Treasurer and a Regent of the College. Edward Martin, Fred B. Lund of Boston, Charles H. Mayo and John G. Clark also represented the Clinical Congress. The joint session was then adjourned and Ochsner called a meeting of the committee of the Clinical Congress. After this meeting, the Board of Regents resumed its deliberations to receive the report of the committee of the Clinical Congress. Again, a joint session of the committee of the Clinical Congress and the Regents was held. On the motion of Frederic J. Cotton, a Regent, seconded by Charles Mayo, both an ex-President and a Regent, a resolution was adopted placing the management and control of the Clinical Congress of Surgeons of North America under the Regents of the American College of Surgeons for the welfare of both organizations. Thus was created one of the present important scientific and educational activities of the American College of Surgeons. The 190 Fellowship of Surgeons changes in the nature of these Congresses have been gradual and have reflected the elevation in the standards of hospitals and the training of young doctors to become surgeons. Operat- ing, or "wet," clinics, with the audience closely packed around the operating table and the surgeon "to see the blood flow," were replaced by "dry" clinics. Matters of diagnosis and treatment were discussed by the surgeon with his audience in the hospital. Today, this latter method has been replaced by teaching motion pictures devoted to specific clinical subjects in a central meeting hall. Sound motion pictures, radio and television have all developed simultaneously with the large number of training hospitals for surgeons. Opportunities for surgeons to refresh their education in postgraduate teaching sessions are inter- mingled with joint discussions of surgical diseases by a panel of experts. Young surgeons, many of them still in their residency, or training, period, find the Surgical Forum the only outlet for the recognition of their efforts as they offer 10-minute presentations of current experimental and clinical research work. William J. Mayo, President of the Clinical Congress of Sur- geons of North America in 1917, acted with Franklin Martin and John Bowman, the Director, to make the necessary revisions in the bylaws which were to be submitted to the Board of Governors of the College for approval. By resolution of the Board of Regents, it was recommended that the President of the College henceforth should be elected by the Fellows of the College. If the Board of Governors approved of this change in the bylaws, the Board of Regents "here and now ratify the election of Dr. W. J. Mayo as President of the American College of Surgeons."7 Ochsner, Edward Martin, John B. Murphy, Fred B. Lund and John G. Clark had served as Presidents of the Clinical Congress of Surgeons of North America but not as Presidents of the American College of Surgeons. Down through the years, this distinction has been lost and the establishment of the first organization to provide postgraduate clinical teaching for a large group of surgeons in practice has almost been forgotten.

4 Excerpt from Minutes of Board of Regents, October 26, 1917. Fellowship of Surgeons 191 Beginning with the sinking of the Lusitania and the loss of the lives of many United States citizens, Germany had consistently continued to provoke the United States Government. The German Government had not kept its promise given through its Ambassador, Count von Bernstorff, that due warning would be given to all vessels, cargo as well as passenger ships, which its submarines might seek to destroy, when no resistance was offered, or escape attempted. Care was not taken that crews be given at least a fair chance to save their lives in open boats. The United States seemed to be slowly and inexorably losing its status of neutrality. Mr. Wilson's hope that a war could be fought according to gentlemen's rules and without involving the bystanders was rapidly fading. War would mean the addition of hundreds of thousands of men to those already provided the armed forces by law. This would require mobilization and allocation of the country's doctors and medical supplies. The country had learned a lesson from the war with Spain. The immediate need for a greater number of doctors than were in the armed forces in 1898 and the haste to add them had resulted in the addition of many incompetent doctors. Some who were responsible for the care of the wounded and sick in that war held only degrees from veterinary schools. The Army Medical Reserve Corps had been organized and 5,000 doctors had joined, but this was only a nucleus around which to build. Frank F. Simpson, a gynecologist from Pittsburgh, and Frank- lin Martin were close friends who had traveled together extensively as members of the American Gynecological Club. Martin had been instrumental in having Simpson elected to the Board of Regents of the College. Their interests in problems related to their profession were similar and their abilities for organization were equally imaginative and thorough. Simpson had previously organized the Committee of Ameri- can Physicians for Medical Preparedness. The presidents of the outstanding national medical organizations were invited to participate. William J. Mayo became the chairman and Simpson the secretary of the committee. Simpson urged Martin to offer 192 Fellowship of Surgeons the help of the American College of Surgeons to Surgeon Gen- eral Gorgas in his efforts to reorganize the Medical Corps of the Army. Gorgas became enthusiastic over Martin's help when 2,000 medical reserve officers were secured from a list of the Fellows of the College which Martin furnished him. Later, in April of 1916, John Finney, as spokesman for the Committee, met President Wilson and offered to the Govern- ment the services of the five medical organizations to aid in mobilizing the civilian and reserve medical resources of the country for its proper military preparedness.° From that time on, Simpson was busily engaged in frequent conferences with the Secretary of War, Newton Baker, and the Secretary of the Navy, Josephus Daniels, as well as the Surgeons General of the Army and Navy. The United States Government was attempting to remain neutral because its citizens were not ready to accept a declaration of war. To the officials in Government, however, war seemed inevitable. Congress was busily engaged in reorganizing the military departments and large military training camps were established. In addition, a bill was introduced to authorize the President to appoint a Council of National Defense.° Simpson worked untiredly to aid in the passage of this bill and to obtain representation for medicine upon the seven- member Advisory Commission. Simpson, without Martin's knowledge, had successfully promoted the latter as the candidate to represent medicine upon the Advisory Commission. On Octo- ber 11, 1916, the White House announced Franklin Martin's name as a member of the Commission. The other members were Daniel Willard, president of the Baltimore & Ohio Railroad; Howard Coffin from the automobile industry; Julius Rosenwald of the Sears, Roebuck Company of Chicago; Hollis Godfrey, a a The American Medical Association, the American Surgical Association, The Congress of American Physicians and Surgeons, the Clinical Congress of Surgeons of North America and the American College of Surgeons represented an aggregate membership of 90,000 doctors. a Newton D. Baker, Secretary of War; Josephus Daniels, Secretary of the Navy; Franklin IC. Lane, Secretary of the Interior; David F. Houston, Secretary of Agriculture; William C. Redfield, Secretary of Commerce; and William B. Wilson, Secretary of Labor, constituted the Council of National Defense. Fellowship of Surgeons 193 professional engineer and president of the Drexel Institute; Bernard Baruch, a financier; and Samuel Gompers, president of the American Federation of Labor. The Advisory Commission was said to be composed of three Republicans, three Democrats and one Independent. However, political obligations of the members were of so little concern that Martin has repeatedly been reputed to have been a Re- publican, much to his wife's delight as she recalled the enthusiasm with which he attended the Democratic national conventions.1° Martin's appointment brought the American College of Sur- geons into national prominence. John Bowman was on hand to direct the educational policies of the Board of Regents, who were in unanimous agreement that a secretary and office should be provided in Washington so that Martin could keep an active hand in the organizational affairs of the College. His main task was to obtain from the civilian medical profession volunteers who would become soldier doctors. Martin took on this responsibility with his customary vigor. The attempts of the American College of Surgeons to raise

1 ° These facts considered with the following quotations shed an interesting light upon the attitude of many of the doctors prominent in the affairs of the American Medical Association concerning Martin's appointment to the Advisory Commission to the Council of National Defense: "A committee of distinguished physicians was asked to present to the president names of medical men for membership on the advisory commission. Dr. Franklin H. Martin of Chicago was selected." (From the Editorial Section, J.A.M.A., 60:1060, 1917.) "On April 7, 1917, The Journal of the American Medical Association noted that war was imminent and called on the medical profession for volunteers. "War was declared on April 4, 1917. It might reasonably be assumed that the American Medical Association was more than cautious in its predic- tions and actions. "As told elsewhere, Dr. Franklin H. Martin had been alert in hastening to Washington; leadership began and remained with him and the leaders of the American College of Surgeons. "It should be noted that in 1917, Charles H. Mayo was the President of the American Medical Association and a Regent of the American College of Surgeons of which his brother, William J., was President." (From A History of the American Medical Association, by Morris Fishbein, Philadelphia, W. B. Saunders Company, 1947, p. 300.) 194 Fellowship of Surgeons the standards of the training of general surgeons had an effect on the group of doctors who were engaged in practice in the only well-defined field of specialization—ophthalmology. Oph- thalmologists had recently established the American Board of Ophthalmology which by examination certified to the fitness of those who wished to practice that specialty. On February 3, 1917, after several conferences with Director Bowman, a plan was presented, the purpose of which was to certify to the Re- gents for Fellowship in the College the fitness of candidates who specialized in the practice of ophthalmology. A credentials committee of the College was approved by the Regents to consist of nine Fellows of the College. Three each were to be selected from the American Ophthalmological So- ciety, the Section on Ophthalmology of the American Medical Association and the American Academy of Ophthalmology and Otolaryngology. These men were at the same time members of the American Board of Ophthalmology which was responsible for conducting the examination. At regular intervals they would be required to report to the Board of Regents full details of the plan and scope of the requirements to be fulfilled for certification as a qualified ophthalmologist. Before the examination was given, the College, on the other hand, reserved the right to submit the names of the proposed candidates for consideration by state and provincial credentials committees as to the moral, ethical and professional character of the candidate. This plan was approved by the Regents, and the activities of the combined American Board of Ophthalmology and credentials committee for ophthalmologists of the College were carried on at the headquarters of the College without secretarial expense or rental fee to the Board of Ophthalmology. It was not until several years later that other boards of examination for the certification of the training of surgeons were established. In the meantime, Franklin Martin became more and more discouraged with the lack of response from universities and medical schools to accept the responsibility for declaring that men who had fulfilled all the requirements of an organized and Fellowship of Surgeons 195 comprehensive training program in surgery and its specialties were qualified surgeons. Martin believed that such a step in the training of their graduates after the diploma was granted would place the qualified surgeon on a high academic plane. It would then specifically point the purpose of the College to aid in continuing the surgeon's medical education and policing his moral, ethical and professional practices. The small number of university medical schools with their own teaching hospitals, the large number of privately endowed hospitals without medical school affiliations, and those state or municipally controlled hospitals in which membership upon the staff was largely a question of political acquaintance and influence were but a few of the obstacles which confronted Bow- man when he attempted to carry out Martin's suggestions in furthering the influence of the College. In addition, again there were those critics who insisted that such a plan would only make Martin more of a dictator than he had already become. Inconsistently, in later years the Regents of the College were criticized for not having taken the initiative in instituting boards of examination for qualification in surgery. Later still, the consensus has been that university controlled and other medical schools should be the sole authority for declaring that doctors are qualified by rigorously disciplined training to be surgeons. Thus, the wheel of opinion has completed a full circle.

On February 3, 1917, at Martin's instigation the Board of Regents sent a letter to President Wilson expressing their unqualified approval of the "just, generous, unyielding and difficult course which you have pursued under unprecedented provo- cation during the last thirty months. . . . " On April 3, 1917, President Wilson again addressed Congress. The new policy of the imperial German Government had swept every restriction aside. On February 3, the President had officially laid before Congress the extraordinary announcement of the imperial German Government that on and after the first day of that month, it was its purpose to put aside all restraints 196 Fellowship of Surgeons of law, or of humanity, and use its submarines to sink every vessel that sought to approach either the ports of Great Britain and Ireland, or the western coasts of Europe, or any of the ports controlled by the enemies of Germany within the Medi- terranean. This had appeared to be the object of the German submarine warfare earlier, but apparently the German Govern- ment had somewhat restrained the submarine commanders. Mr. Wilson announced that even hospital ships which carried relief from the United States to the starving people of Belgium, though they were provided with safe conduct through the areas proscribed by the German Government and were distinguished by unmistakable marks of identity, had been sunk without compassion. The President said that he had thought it would suffice to state strongly the neutral rights of the United States to use the seas against unlawful interference and to protect United States citizens against unlawful violence by the use of arms. He had been mistaken, he said, and had painfully come to the conclusion that German submarine warfare against commerce was a warfare against mankind—a war against all nations. Mr. Wilson assured Congress that it was with a profound sense of the solemn and tragic nature of the step, but also with an unhesitating obedience to what he deemed his constitutional duty, that he advised it to declare the course of the imperial German Government to be nothing less than war against the United States. Further, he advised that Congress accept the status of belligerency which had been thrust upon it. On April 4, 1917, by the act of Congress, the United States declared war on Germany. CHAPTER 6

RESIDENT WILSON had appointed Franklin Martin to the r Advisory Commission of the Council of National Defense on October 11, 1916. Martin had spent the following year traveling to and from Washington, working diligently to stimulate enlistment of the medical profession in the medical corps of the armed services. John Bowman and faithful secretaries, together with some of the members of the surgical journal staff, had been able to assume many of the routine chores necessary to arrange for the Clinical Congress and annual meeting of the College. Martin's professional practice had suffered proportionately, and it was a matter of great concern to him to face the fact that by necessity, though not because of the choice of his patients, he was unable to be a practicing surgeon. In spite of the early protests of representatives of the Ameri- can Medical Association, Martin had been appointed to the Advisory Commission. The Association's Trustees believed that their organization was truly representative of the medical profession and that the College of Surgeons was not. Their opposition was addressed to the President, the Secretary of War, the Surgeons General of the Army and Navy and to other government officials. Occasionally, the criticisms were open, but more often they were veiled. Arthur Dean Bevan was president-elect of the American Medical Association in 1917. He had succeeded to the chair of surgery at Rush Medical College when John B. Murphy insisted that Bevan be appointed as his co-chairman. Soon thereafter Murphy left to go to Northwestern University. It was Martin who had brought Bevan into The Chicago South- Side Medico-Social Society. 198 Fellowship of Surgeons To whip up enthusiasm in the profession for the military effort, Martin had proposed the establishment of the Volunteer Medical Service Corps of the United States. The object of the Corps would be to establish an emergency medical organization to perform, when required, such civic and military duties as were not provided for by law. Those physicians would be eligible for membership who were not acceptable in the medical reserve corps because of physical disability, essential public or institutional need, dependents, or because they were past 55 years of age. Calls for the services of these individuals would come from a Central Governing Board upon request from the General Medical Board of the Council of National Defense, which Martin had created to be representative of the entire profession, and the Surgeons Gen- eral. Martin had an inherent knack for proposing that such a Corps should have officers, an executive committee and state governing boards. Such an organization would, in effect, consist of a roster of the physicians of the country and would make it unnecessary to consult the records of the American Medical Association. Each member of the Corps would be authorized and encouraged to wear the insignia which could be obtained and worn only under the strictest regulations. This recognition of the efforts of physicians who had to remain at home and examine draftees received an immediate enthusiastic reception. It also stimulated younger and healthier doctors, whose professional roots had not had time to become unalterably fixed, to join the medical reserve corps and seek active duty with the troops. The Regents had met several times in New York and Wash- ington after the declaration of war. However, the annual convocation and Clinical Congress were held in Chicago in the fall of 1917. The Surgeons General William C. Braisted of the Navy and Rupert Blue of the Public Health Service, Colonel Thomas H. Goodwin, the representative of the Director-General of the Royal Army Medical Corps, and Colonel C. U. Derele, official representative of the Medical Corps of the French Army, were Fellowship of Surgeons 199 to receive Honorary Fellowships in the College. The other recipient of an Honorary Fellowship was Sir Berkeley Moynihan, universally compared to John B. Murphy, as his British coun- terpart in surgery. Moynihan brought the audience to their feet at the end of his convocation evening address. He began by saying: 1 At midnight on August 4, 1914, England, to her lasting honor, declared war against Germany. At 8 a.m. on August 5, 1914, I became a soldier of my Sovereign. Believing that the full quota of doctors could be supplied from its own ranks by inspiring articles published in the Journal, the American Medical Association had taken no positive action at its convention the preceding June. Charles Mayo had assumed office as president, with Arthur Dean Bevan as president- elect. The Bulletin of the Chicago Medical Society, generally conceded to be the organ through which influential Chicago members of the American Medical Association expressed their views, openly urged physicians not to join the Volunteer Medi- cal Service Corps. It was no reflection on a doctor's patriotism if he did not join, it said; such action showed instead an independence of spirit. For six months, plans had been formulated to utilize the Clinical Congress and the convocation of the College of Sur- geons for demonstrating the further need for medical officers in the armed services. The Surgeons General of the Army, Navy and Public Health Service were granted leave to attend and to speak. George Crile, the President, was given leave to return from his military assignment in France with the base hospital which he had organized. Clinical demonstrations and symposia concentrated on v ari- ous phases of modern military surgery, which included advances in methods for caring for the sick and wounded as they had been developed through the previous three years. H. D. Dakin and Alexis Carrel were scheduled, but did not appear, to participate in a discussion upon the use of antiseptics, particularly

1 Moynihan, B., England and the Great War. Surg. Gyn. Obst., 25:707,1917 200 Fellowship of Surgeons dichloramine-T which had become popularly known as "Dakin's solution." It was claimed that this solution, properly used, had the property of killing bacteria without injuring tissue. Introduced into an open, infected wound, it greatly accelerated healing. Moynihan deftly assailed this method of treating gunshot wounds and said it had achieved its greatest success in cases in which it need never have been used. The October issue of Surgery, Gynecology & Obstetrics carried on its front cover an advertisement from the W. B. Saunders Company for the Treatment of War Wounds by the nestor of surgery, W. W. Keen. Keen's book contained contributions on the removal of foreign bodies, the Dakin-Carrel method of treating infected wounds with dichloramine-T, gas bacillus infections and gas gangrene, glue adhesive tape for obtaining extension in the treatment of fractures and the par- affin treatment of burns. As an added feature to sell the book, there were letters from Harvey Cushing, Joseph Blake, George Crile, Anthony Bowlby and others concerning their personal experiences in the treatment of wounded soldiers in France. In accord with the wishes of the Board of Regents, John Bowman had been visiting doctors over the country and learning about the administration of hospitals preparatory to initiating a set of minimum requirements which the College could reasonably expect might be met by the majority of hospitals in operation. Franklin Martin's personal efforts in Washington were advancing the reputation of the new organization of surgeons nationally and internationally. Because of his duties in Wash- ington, Martin had enlisted the services of an old friend, Walter E. Carr, experienced in the real estate business, to continue the campaign for gifts to the Memorial Association from which a monument to John B. Murphy and the permanent home of the College might be forthcoming. From the beginning of the first Clinical Congress of Surgeons of North America, Martin had declined any compensation for his administrative conduct of the two organizations. He had spent freely of his own money; in fact, he had continued to Fellowship of Surgeons 201 be primarily interested in his large and lucrative practice of surgery which had always been dominated by patients with gynecological disorders. He had hoped that the administrative affairs of the College of Surgeons could be conducted by a well chosen staff, as he had often outlined, under the policy direction of the Board of Regents, all of whom would always be surgeons. However, there had been the repeatedly expressed opinion among the Regents that a Director without experience in the medical profession, let alone not a surgeon, might have difficulty in understanding the practical problems confronting hospitals and doctors. In adhering to the ideals which they wished to promote, such an individual might well be impatient and in- tolerant when the opposite attitudes would bring ultimate success. Bowman was a straight hard hitter with characteristics about which Franklin Martin could express himself with contagious enthusiasm. Bowman had told the American Hospital Associa- tion that the College of Surgeons was pledged to the most idealistic program ever expressed in any profession. He said, "Its program includes the elevation of the standards of medicine, moral as well as intellectual. It is a guarantee of no indefinite sort to the public of honest and competent surgery. It is an association to encourage scientific advances in medicine and surgery. It is a national force to put an end to guesswork in diagnosis, to put an end to unnecessary operating, and to blot out the vicious practice known as the division of fees. Better probably, than any group of men and women who gather themselves together in this country, you know the extent of these evils and of the unnecessary pain and death that trail in their wake."2 These were strong words which were not contradicted but which some surgeons thought should not be expressed so directly for public consumption. They said it was washing the profession's dirty linen in public. Several of the Regents, though they did not disagree with the principles expressed, hoped that

2 Address before the American Hospital Association, 1918 (unpublished). 202 Fellowship of Surgeons such plain speaking would be avoided and that, painlessly and with great righteousness, reform would spontaneously envelop the surgical profession. It was difficult for these men to believe that there were those among the profession who would work actively to prevent the slightest interference with their methods of practice which they considered their constitutionally given and inherited rights. Martin became ill just as the annual meeting began in Chi- cago on October 21, 1917. In an attempt to keep close to the activities of this wartime meeting for which he had planned in such detail, he would arise and then be forced to return to his bed in the Congress Hotel. He could not attend the meeting of the Regents on the morning of October 26, but William Mayo, George Crile and Edward Martin were designated by the Regents to convey to him that afternoon the action which the Board had taken. On motion of Edward Martin of Phil- adelphia, supported by Frederic Cotton of Boston, the Regents had elected him executive officer of the American College of Surgeons. He was to have the title of Secretary-General, for a period of seven years with an annual salary of $10,000. The annual salary would be increased to $15,000 whenever he chose to devote all of his time to the affairs of the College!' They pressed him for an immediate answer. He begged time to give such an important matter serious consideration of which he was incapable then because of his illness. He became angry and said that if they expected to deal with him at all, they would have to leave the disposition of his future activities in his hands.4 Before returning to Washington after the Clinical Congress, Martin remained in Chicago for a few days struggling with the problem which his friends had imposed upon him. Many hours were spent with his wife, Isabelle, discussing his love for his surgical practice, the affairs of the surgical journal, the strength of the College of Surgeons and its future influence upon the

3 From Minutes of Board of Regents, October 26, 1917. 4 Martin, F. H.: The Joy of Living—An Autobiography. New York, Doubleday, Doran & Co., 1:441, 1933. Fellowship of Surgeons 203 practice of surgery, the demands upon his time which came from his position on the Advisory Commission, and the attributes of Bowman, Kanavel and his other young associates who were engaged in their own military duties. The abilities of his several, efficient secretaries helped make his tasks lighter. One evening after they had finished dinner, he again began to talk and pressed her for an opinion which purposefully she had not expressed. 5 Finally, as he paced up and down the room, Mrs. Martin told him that perhaps it would be better if he stopped the practice of surgery at a time when all of his patients sought his services, rather than to postpone such a move until a time when they might well call upon a younger man to care for them. Without another word, Martin put on his hat and topcoat and left their apartment. He walked the streets for hours, shocked beyond words by the realization that what his wife had said might well come true. Finally, at midnight he returned. "Put on your dressing gown, Squiggie, and come out here." Martin led his wife across the room to the windows which faced their beautiful Lake Michigan on whose shores they had lived since their marriage. Pointing to the ground 10 floors below, he said, "You don't know how close you came to being thrown right out that window when you said I'd better stop practicing while my patients still wanted me. Now, I know you are right. I'll give all my time to the journal and the College when I get through with this Washington job." Attacks emanating from Chicago on the activities of the Col- lege had emphasized the lack of need for such an organization because the American Medical Association was an efficiently functioning representative of the medical profession. The campaign shifted to one characterized by innuendoes. It was said that the College of Surgeons was the business of one man aided and abetted by a few of his cronies. The seeds of suspicion were planted that Franklin Martin was becoming rich from the moneys taken in by the College. From the beginning, strict accounting and auditing methods

6 Personal communication from Isabelle and Franklin Martin. 204 Fellowship of Surgeons had always been practiced in the affairs of the Clinical Congress of Surgeons and the College. As the organization became stronger and to meet any objections which might be raised as to procedure, the Regents carefully revised and followed rules laid down in the bylaws. On December 10, 1917, the Board of Governors approved changes in the bylaws, which the Feb lows had adopted in Chicago the previous October, to legalize the merger between the Clinical Congress and the College and to make the election of officers and Regents more democratic. The President and two Vice-Presidents were to be elected annually by the Fellows of the College. Fifteen of the 16 members of the Board of Regents would be elected from among the Fellows by the Board of Governors "in a manner to be determined by the Board of Regents." The sixteenth member would be the President of the College. The holder of the new position of Secretary-General would be the chief executive officer of the College who, under the direction of the Board of Regents, would have supervision of all activities and business affairs of the College. He would be required to attend all meetings of the Board of Regents and would hold office during the pleasure of the Board. The Direc- tor of the College would be the chief executive officer of the educational activities, under the direction of the Board of Re- gents, including admission to Fellowship and hospital standardization. Many of the Regents believed that after many years of devotion and hard work, an organization had finally been created which was democratic in principle and spirit and was devoted completely to the elevation of professional and hospital standards which would benefit the patient. John Bowman had been traveling over the United States and Canada visiting doctors in their offices and hospitals, as he has said, "with his grip in one hand and his hat in the other."' He had come more firmly to the opinion that the admission to Fellowship based upon records submitted by the candidates was inextricably bound to the poor quality of the records of

11 From personal interview of John G. Bowman by Greer Williams. Fellowship of Surgeons 205 hospital patients. In fact, in many hospitals no record of the clinical progress of the patient existed. It was true that the Council on Medical Education of the American Medical Association was attempting to determine the quality of hospital care, as related to the education of the intern, but no steps had been taken to implement its findings. Bowman found that it was argued that the hospital had no particular obligation to meet in the intern's education. It was a more convenient place, it was held, than the home in which to perform an operation and for the patient to remain during his convalescence. The hospital's sole obligation was to furnish space with proper heat, light and food for the patient. When these services were paid for by the patient and he was discharged, the hospital's interest and obligation to the patient ceased. The doctors considered hospital staff meetings as impositions upon their busy lives. No particular benefit could be derived from these clinical sessions, it was argued, inasmuch as the majority of patients were private, or pay, patients who would be offended to have their problems discussed among the staff members in consultation. What right did any group of "do-gooders" have to require a minimum routine laboratory examination of the blood and urine? The patient should not be put to the added trouble and expense of these examinations except when the doctor deemed these tests advisable for his own information. To record a positive reaction of the Wassermann test for syphilis was considered particularly obnoxious and subject to embarrassing legal action. Just why, it was asked, should the surgeon be required to record on the hospital chart the reason for operating upon the patient, as long as he was licensed to practice and was to do nothing criminal? It was his business and that of his patient. To require that he write down in detail over his signature just what he had done at the operation was carrying matters too far—this was a violation of the patient's privacy. To demand of the busy surgeon that he make, or supervise the making of, a 206 Fellowship of Surgeons record to which he personally would add notes of the patient's history, physical examination and clinical course following operation and to summarize and state the condition of the patient at the time of discharge from the hospital would put a burden upon him which would be too much to expect him to carry, even admitting that such a record would be of value. To whom would such a record belong? This question started many heated arguments. Finally, it was claimed, the fee-splitting question had nothing to do with the treatment of the patient. Why should any hospital administration meddle with the surgeon's business arrangements? It was an affront to the dignity of the profession for a hospital organization to insist that its staff members pledge themselves not to split fees. As long as the patient got his money's worth, of what interest was it to him how the fee was divided? What good would it be to have a doctor sign a pledge against fee-splitting if he would not live up to it? Ultimately, came the final charge. "There are plenty of men who are Fellows of the American College of Surgeons who split the patient's fee every day of their life." "Give us their names, doctor." "You fellows know who they are. You don't expect me to have a lawsuit on my hands, do you?" It was difficult for the medical profession to realize that the days of the solo doctor were passing rapidly. The development of anesthesiology, pathology, roentgenology, dietetics, nursing and surgical techniques made every doctor a member of a team whose efforts had to be co-ordinated, synchronized and controlled for the best interests of his patient. Bowman was quite aware that he would have to obtain the complete co-operation of the administrators of hospitals before any plan of standardization could be successful. Quickly, the American Hospital Association gave its support. Bowman was able to enlist the interest and support of the Reverend Charles B. Moulinier, S.J., president of the Catholic Hospital Associa- tion. However, the question remained as to whether help would come from the Catholic Church authorities. Fellowship of Surgeons 207 An audience was arranged with James Cardinal Gibbons of Baltimore for Franklin Martin and John Finney to discuss the hospital standardization program. After due consideration, Cardinal Gibbons assured them of his interest in and approval of the plan to reach "the highest state of efficiency possible in each hospital." Formal endorsements were also received from the Protestant Hospital Association and the Board of Hospitals, Homes and Deaconess Work of the Methodist Episcopal Church. A questionnaire would have to be prepared and sent to hospitals so that information could be gathered upon which a practical program of standardization could be based. In addition to a standard of operation, there were many other things which had to be known in order to bring the best result to the patient. How was the hospital organized? How were the nurses trained? Was there abuse of the training school for nurses? What was the cost per patient per day and how was it determined? Did the hospital function as a teaching and research institution? Could the American College of Surgeons appoint surveyors who would investigate each hospital and then call together the board of trustees and the medical staff and tell them in a kindly spirit exactly what they had found and how it could be corrected. To determine the answers to these questions upon which the success or failure of hospital standardization would rest, Bow- man arranged a conference on hospital standardization which was held on October 19 and 20, 1917, during the Clinical Con- gress of Surgeons in Chicago. The meeting was a tremendous success with an attendance of over 300 people, representing 60 hospitals. Edward Martin, a more extroverted champion of hospital standardization than Ernest Codman, and Dr. John A. Hornsby, editor of the magazine, The Modern Hospital, spoke on the existing status of hospitals. Ernest A. Codman and Allen B. Kana- vel, members of the first committee of the College, spoke with Dr. John Young Brown, Professor of Surgery at St. Louis Uni- versity School of Medicine, Dr. Francis C. Wood, director of 208 Fellowship of Surgeons laboratories at St. Luke's Hospital in New York and Miss Annie W. Goodrich of the school of nursing of Columbia University on the topic "What the Profession of Medicine Wants in Hos- pitals." Dr. E. P. Lyon, Dean of the University of Minnesota Medical School, Mr. Asa S. Bacon, superintendent of Presby- terian Hospital in Chicago and Father Monlinier, representing hospital administrators, spoke on the practical aspect of approaching the problem of obtaining hospital standardization. The outcome of the conference exceeded the hopes of Bow- man and the doctors and laymen who had joined him in the attempt to put into force the idealistic program to which the American College of Surgeons was committed. The idea of organized standardization advanced among those present from a mere intellectual concept into enthusiasm for a real practical program. Interest in the project had been demonstrated to be shared by hospital administrators of large and small hospitals and by doctors. Agreement was unanimous that the proper care of the patient was the final test of efficiency of the hospital. It became clearly apparent that closer co-operation was needed between the medical staffs and hospital trustees with strong, efficient administrative authority. In order to translate these conclusions of the conference into quick and firm action, a General Hospital Committee of 25 members to be composed of physicians, surgeons, hospital super- intendents and laboratory specialists was appointed to meet in Washington, D. C., on December 8 and 9, 1917. This committee was assigned specific duties. It was to revise and complete the questionnaire upon which data concerning hospitals were to be collected and to review and complete a minimum standard of efficiency which would be the basis of hospital standardization. Dr. Arthur Dean Bevan, chairman of the Council on Medical Education of the American Medical Association, took part in the conference in Chicago. Originally, he had been asked if the Association should not undertake the problem of hospital standardization. The Board of Trustees of that organization had considered the expense of such an undertaking, Bevan said, and had decided not to accept the responsibility of the task. This Fellowship of Surgeons 209 had left the College of Surgeons to undertake the project, if it saw fit, and quite definitely placed an important responsibility upon its shoulders. In his discussion during the conference, Bevan said:

I have been very much interested in this whole problem for a number of years, and I want to congratulate the College, first, and very emphatically, upon the splendid way in which this movement is evidently being started. . . . It is a splendid thing to get a fine body of men interested in this problem as you are today. . . . To my mind, next to the work that has been done in medical education in this country this problem that confronts your committee today is the most important thing in American medicine. . . . We should get as support in this movement the American Medical Association and co-operate with that association. You must remember, that in a hospital we have not only surgeons and surgical specialists, but medical men and medical specialists, many of whom are not in close touch with the American College of Surgeons?

It appeared that Bevan's remarks constituted a blessing from the American Medical Association which satisfied its curious, and at times completely unsatiable, desire to be recognized as the tree from which all other medical societies sprang and in which all progress within the medical profession originated. As a result of the deliberations of the committee appointed to find ways and means of putting the hospital standardization program into effect, at a meeting held in Washington on De- cember 8 and 9, 1917, a questionnaire to obtain information was sent to 2,711 hospitals in the United States and Canada. An invitation to participate in the study was sent to each hospital and a list of the questions was sent to each Fellow of the College asking him to co-operate and help his own hospital to furnish the information desired. John Bowman outlined his conception of the methods of pro-

'Bull. Am. Coll. Surgeons, 3:1, 16, 1917. 210 Fellowship of Surgeons cedure on more than one occasion and to more than one group of interested parties. He insisted upon establishing a minimum standard which would be concise and practical. Any hospital which failed in any one of the essential particulars would not be listed as a first-class institution, because it could not render fair and competent service to the patient. It would be necessary, Bowman pointed out, to engage as surveyors of hospital services doctors who would report upon the hospital's standing according to the standards established. If a hospital did not qualify, the reasons therefor would be explained to the trustees and staff. The hospital would then be given six months to a year to correct the defects, following which it would again be surveyed. Time and again Bowman emphasized that changes would not be made because a national organization of surgeons set up a set of standards, but because it was the right thing to do for the patient and because the American College of Surgeons program was a friendly one which would help each hospital in its efforts to meet the need of its community in the best possible manner. There were two methods by which the standardization program could proceed, Bowman said. One was scientific and the other was human, but they were not entirely exclusive, one from the other. The difference between them was that "between a gift of lasting worth as against an uninvited interference of doubtful value." The scientific method, he said, had wrecked many a worthy project of reform and prejudiced men against all systematic progress. The human method would never forget the point of view of others. It assumes that men are intelligent and open-minded and it would value straight thinking and accurate data.8 As Bowman traveled about the country and as he directed the efforts of the College program, his well-intentioned presentations were resented as being dictatorial. He was charged with being a schoolmaster who was pedantic and who did not really attempt to see the viewpoint of others. Nevertheless, he was a 8 Concerning Hospital Standardization, Surg. Gyn. Obst., 29:113, 1919. Fellowship of Surgeons 211 catalyst which made doctors and hospital administrators think and try to express their own views about the standards which the hospital of 50 beds and the one of 1,000 beds should have in common. Bowman did not have an easy task arousing and sustaining interest in an ideal in the midst of the tragedy and hysteria of a world war. On the other hand, those very circumstances permitted another minority-supported ideal to advance in a few months, more than it had progressed in years. On Decem- ber 18, 1917, the Volstead Act prohibiting the sale of liquor was passed by Congress and submitted to the states for ratification as the Eighteenth Amendment to the Constitution. Ninety per cent of the 3,795 Fellows of the College of Sur- geons had volunteered for military duty. Medical students were placed in the enlisted medical reserve corps to continue their studies. Without any insignia to distinguish them, medical students were subjected to the freely used insult of "slacker" applied to any healthy-looking young man who was not in uniform. Base hospitals, staffed by members of the faculty of medical schools and the staffs of hospitals, had been quickly organized. While waiting for orders, the doctors, wearing ill-fitting uniforms and leather puttees, drilled clumsily on adjacent vacant lots and children's playgrounds. Obstetricians, nose and throat specialists, internists and surgeons were all asked to forget their specialty to become a military doctor. Many were given military ranks which produced great hardships on their families and handicapped their efforts to apply their professional skill efficiently and properly. Some time had elapsed since the declaration of war in April, but the effect of the American Expeditionary Force had not been realized. Hindenburg had succeeded von Falkenhayn as chief of staff of the German field armies with von Ludendorff as quartermaster-general. Nivelle had succeeded Joffre as head of the French armies and immediately had come into disagreement with Douglas Haig, the British commander, concerning the execution of an advance on both sides of the Somme. In the mean- 212 Fellowship of Surgeons time, the Germans straightened and strengthened the western front. Submarine warfare by Germany had reached its highest point with the destruction of about 8,000,000 tons of shipping. The hazards of transporting the United States forces to France had been great. In June of 1917, Nivelle's offensive had failed and he had been replaced by Petain. Haig began a British offensive in Flanders which resulted in the third battle of Ypres and cost the British a demoralizing number of men. Slowly, Pershing was assembling the United States forces for participation. The contributions of American medical men and hospital units to the allied effort had been numerous and effective both to the Brit- ish and the French. Even before his soldiers had been engaged in battle, however, President Wilson had outlined his peace program of fourteen points. General Foch was named commander-in-chief of the Allied armies in France, though each national commander retained extensive control of his own forces. Finally, the Ameri- can second division broke through the advancing German army at Chateau-Thierry in collaboration with the French on June 4, 1918. In the middle of July, the second battle of the Marne began and immediately afterward the allied forces went over to a sustained offensive. The Battle of Amiens, in which the British used 450 tanks, the second battles of the Somme and of Arras, and the highly successful American attack on both sides of the St. Mihiel salient were followed rapidly by the successful battles of the Meuse-Argonne, St. Etienne and Sedan. These severe blows, together with the news of the surrender of Bulgaria, caused von Ludendorff to demand on September 29 that his government seek an armistice and peace negotiations. Franklin Martin had seen no reason why plans should not go forward for a Clinical Congress and a convocation of the College in the fall of 1918. Several meetings of the Board of Regents were held in Washington and in New York during the year, often informally because of the lack of a quorum. Finney was serving as the Chief Surgical Consultant to the Army in France Fellowship of Surgeons 213 and most of the other Regents were in uniform in one capacity or another. In spite of arguments from the Regents, Martin had persisted in going forward with plans for the annual meeting. Finally, the onset of a pandemic of influenza which decimated the armed services and the civilian population forced him reluctantly to abandon the plans. However, he insisted, and the Regents agreed, that they confer the Honorary Fellowships upon the men who had been chosen for the honor and who had planned to be in the United States at the time which corresponded to the annual convocation of the College. On the evening of November 2, 1918, the Chicago Surgical Society gave a dinner for the distinguished foreign guests who had arrived in Chicago from the Mayo Clinic which they had visited in Rochester. Martin had met obstruction from Bevan, Malcolm L. Harris, a Chicago surgeon high in the councils of the American Medical Association, and George Simmons, editor of the Association's journal. Nevertheless, the dinner for Sir Thomas Myles of Dublin, G. Gray Turner and George E. Gask of London, Pierre Duval and Henri Beclare of Paris and Raffaele Bastianelli of Rome was a great success. The visitors returned to New York. On the evening of No- vember 6, a dinner was held at Delmonico's restaurant, attended by the local Fellows of the College, with the mezzanine graced by their ladies. Myles, Turner, Gask, Duval, Bastianelli and Merritt Ireland, the newly appointed Surgeon General of the United States Army, were presented for Honorary Fellowship in the College. Sir Thomas Myles made the speech of the evening with an impassioned, stirring eloquence sprinkled with Irish wit but with a strong protest against dealing leniently with the Huns. Mutiny had broken out in the German fleet at Kiel and on the following day, November 7, a revolution occurred in Munich. Two days later, Kaiser Wilhelm II abdicated and fled to Holland. The appeal of the German and Austrian Govern- ments to President Wilson for an armistice, accepting his proposed fourteen points, was granted. On November 11, 1918, 214 Fellowship of Surgeons hostilities ceased, and the demands occasioned by e rapid mobilization of military and civilian resources in the United States were quickly relaxed. The short participation of the United States in World War I had not been anticipated. In fact, plans had been projected for a long struggle and the campai to get more doctors and nurses to volunteer for service was at its height. Martin had traveled extensively, ;speaking before medical societies and ups of laymen. Arthur Dean Bevan had been inaugurated as president of the American Medical Association in June. In his inaugural address he had asked e rhetorical question, "Who represents the .edical profession?" ie en answered his own question by saying: The e dent organization of the medical profession of this country for war is being .splen •"My accomplished by the co- operation between the Medical Departments of • e Army and Navy and the organized profession, the American Medical As- sociation. It has been unfortunate that a medical advisory committee which is not in any way represen r. tive or democratic, and Which has no proper function in the e dent organization, of the mee cal profession for war, Should have been called into existence. .A small coterie of specialists, of gynecolo 7sts and surgeons, no matter how eminent or how successful they may have been as promoters and exploiters of special me 'cal so., cieties, can in no way in this great emergency and in this great democracy represent the medical profession, Bevan went further in his e l orts to dislocate and disrupt the medical representatio upon the Advisory Commission to the Council. of National Defense. He wrote a letter to President Wilson requesting that Franklin. Martin be removed from the Commission. The President forwarded the letter to Newton aker. Secretary of War and Chairman of • • e In turn, Baker sent a e letter to Surgeon General Corps who asked for mments. evarr, ,Artlittr; Dean: The ration of the 1..it:di Profession ,for War. 70:1800,1918., Fellowship of Surgeons 215 Gossip had spread the word that Martin wished to succeed Gorgas, whose term as Surgeon General was about completed. Martin replied saying that he would be quite satisfied with any decision which the Chairman of the Council of National Defense believed was the correct one." The answer came in a complimentary letter from the President to Martin praising the work he had done and the co-operative spirit he had shown in the deliberations of the Commission. Simultaneously, the House of Delegates of the American Medical Association was the scene of a struggle for power which centered in the election of the president-elect. The candidates included Braisted, Surgeon General of the Navy, J. M. T. Finney, Frank Billings and Alexander Lambert. Lambert was backed by Bevan and held similar views about the place of the American Medical Association in representing the medical profession. Now that the war was finished, Martin planned upon his return to give his time completely to the affairs of the College of Surgeons. The most important question concerned the standardization of hospitals. Second only to it was to locate the College in a permanent home. Before Martin could finish the odds and ends necessary to complete his work, John Bowman telegraphed him that William J. Mayo, President of the College, wished to arrange a meeting between the Regents and the Trustees of the American Medical Association. Mayo sought a close alliance between the two organizations with the motive of bringing general peace within the medical profession. Mayo had been active politically within the House of Delegates of the American Medical Association in attempting to make J. M. T. Finney of Baltimore or Frank Billings of Chicago president-elect of the Association." Mayo was deeply chagrined and discouraged by his introduction to the animosities and personal jealousies present within the As- sociation, as well as the dog-in-the-manger attitude of the majority of the Trustees toward the College of Surgeons. 10 Excerpt from Franklin H. Martin's diary. 11 Excerpt from Franitlin H. Martin's diary. 216 Fellowship of Surgeons Upon taking office as president of the American Medical Association, Bevan, who served as chairman of the Council on Medical Education, proposed to broaden the scope of the Coun- cil's interests and include the standardization of hospitals. The Council on Medical Education came into existence with the founding of the Association in 1847. It had concerned itself with the standards of teaching in medical schools and, later, in the hospital internship. However, it had never been concerned with the end result of the care of the patient as far as clinical records, laboratory and x-ray services were concerned. In fact, Bevan had said that this was too extensive and too expensive a task for the American Medical Association to assume when the Regents of the College had proposed that this function belonged properly to the American Medical Associa- tion. After the successful conference on hospital standards which had been held in Chicago under the auspices of the College, the Council and Trustees had evidently changed their minds. Mayo arranged the meeting which Martin was unable to attend because he was ill with influenza in Washington. He was, however, able to write his friend, Mayo, a letter expressing his views: The American College of Surgeons to me is what the Mayo Foundation is to you. I have put the best of everything I have in me into it and I am very zealous for its future and that it shall be properly nursed during the next three or four years. The hospital program is one that was carefully developed by us after first ascertaining definitely that it was not a job that was being done by the American Medical Association and after a conversation with one or two members of that association and Mr. Bowman, in which he was assured that the field was open to us. Martin said that the first year's work had been preliminary because of inexperience but it had not been fruitless. Bowman had been able to work out a plan which would make it possible to create a level of hospital standardization in an effective way without antagonizing hospital trustees and administrators. The letter clearly expressed Martin's indignation. Fellowship of Surgeons 217 During all our work, we have never received the slightest encouragement from the great democratic parent body but on the other hand, they have been distinctly hostile not only to every one of our plans but to the College itself and always without stint to its real founders. To me your proposition to call a meeting of the Board of Regents to go directly in joint session with the Trustees of the American Medical Association when I am unable to be present, is like some one in Minnesota calling a meeting to discuss the affairs of the Mayo Foundation with the idea of taking over a portion of its functions while you, the founder of the Mayo Foundation and the one most interested in it, are lying away somewhere in bed, and this meeting being requested to be with the very group of men who have fought your Foundation bitterly and relentlessly—the way I know men have fought it from the beginning. Addressing Mayo with a "Now, listen," Martin continued to point out that if it was desirable for the American Medical As- sociation to divide the work, which the College had already planned and was doing, then it was proper for the Regents to be called together preliminarily to discuss the affairs and policies of the College. This had been impossible, he said, because many of the Regents who had been active in the College from the beginning were overseas. It was important to obtain the judgment and advice of those men in addition to the Johnny- come-latelys. It would be fatal to the College to plan to combine its Clinical Congress with the annual meeting of the American Medical Association, he wrote, expressing his opinion upon one of the proposals to obtain harmony. Martin continued: The American College of Surgeons either has as great a function as the Royal College of Surgeons of England has, or there is no reason for its existence at all, and a lot of us believe that there is a very definite reason for its existence. Martin had written to Bowman and expressed the opinion that Will Mayo's plan for a meeting would only effect an alliance between a small group of Regents, not backed by a 218 Fellowship of Surgeons decisive consideration of the problems by the entire Board, and a small clique in the American Medical Association, who he had reason to believe were not "on the square" and who did not represent the rank and file of members of that organization. Mayo wired Bowman that he had heard from Martin and was sorry he could not attend the meeting but that it would be held with independent discussions of propositions which might be for the best interests of the profession and the people they were striving to serve. In another telegram, followed by a letter, to Martin in Washington, Mayo made the same statement and added that they could adjust any differences which would not interfere with the future usefulness of the College. He assured Martin that no move would be taken of which he would not approve if he were present, as he stated: Bless your old heart! You will find that we will be quite able to cope with that bunch even if you are not there. And we won't do anything foolish. I have a few little surprises of which I know you will approve. It is not our councils that are to be divided. We will take no permanent steps without submitting them to you and all the Regents, but there are some very good reasons for having this meeting now with as many of the men present as we can get together, because these Regents are outstanding men and their presence will be impressive. As President of the College, Mayo assumed prerogatives which Finney and Crile had kept within the Board of Regents as a body. The meeting with the representatives of the American Medi- cal Association was held in Chicago on the afternoon of Febru- ary 7, 1919. Mayo, Ochsner, Crile, Simpson and Bowman represented the College before a regular meeting of the Board of Trustees of the Association. Bowman stated that the work on hospital standardization was at the moment centered upon clinical case records, laboratories and staff organization and that personal inspection of the hospitals was made. Mayo said that the College wished to bring about a sympathetic understanding and co-operation between the two organi- Fellowship of Surgeons 219 zations and that duplication of work should be avoided. The upshot of a mild and ineffectual meeting, at which the College was inadequately represented, in comparison, was that Bowman and Colwell, of the American Medical Association, were instructed to keep in close touch with each other in all matters pertaining to hospital work. Simultaneously with the attacks by Bevan and his supporters in the American Medical Association upon the activities of the College, innuendoes and personal charges were scattered about that certain individuals were making personal fortunes out of the College as they had from the Clinical Congress. Others besides Martin were included in "the ring." At the annual meeting of the Fellows of the College in New York on October 23, 1919, Dr. George David Stewart read the report of a committee which the President, William J. Mayo, had appointed to audit the books of the Clinical Congress of Surgeons of North America and the American College of Surgeons which had been merged. Mayo appointed himself chairman. To the committee, he added Bevan, Stewart, William W. Pearson of Des Moines, Iowa, and Miles Fuller Porter of Fort Wayne, Indiana. Each member of the committee signed the report which stated that the accounts of both organizations were correct in every respect, the methods of bookkeeping were accurate, and proper vouchers and receipted bills were on hand for all moneys paid out. The report added that no money had been spent without proper authority and only for value received. This committee's report ended the charges of financial irregularity and grafting. In accepting a place on the committee, Bevan had gambled and lost. Encouraged by the reception of the questionnaire sent to the hospitals, Bowman began to visit institutions of 100 beds or more in the hope of discovering a definite starting point ox minimum level of standardization which was practical and workable and which could be within the reach of the 50- or 100-bed hospital, as well as the one of 1,000 beds. It became more and more evident that no hospital could be used as the perfect model to meet all the conditions which the participants in the conference had considered to be ideal. 220 Fellowship of Surgeons In retrospect, the results of the initial surveys and questions appear to be unbelievable. There was too much operating by the clock. The wealth of patient material was utilized in no way except for added experience; patients were insufficiently studied before operation. The fracture dressings were so neat and laboriously applied that the surgeon hesitated to remove them to see that all was well beneath. Students were tolerated and a great many surgeons and physicians forgot how recently they had been sitting on the medical school benches. There was a great display and operating room technical rivalry at the usual Saturday morning exhibition of skill. There was little or no encouragement to produce and contribute to the surgical literature for the progress of medicine; no stimulus to follow up a bad result either to the patient's home or the autopsy table. These faults were not peculiar to one hospital alone; they were merely an expression of the times. As Harvey Cushing said: We ( the residents and interns) controlled the staff, in our estimation, who by suffrance did such operations as we allowed, and the Almighty with our help cared for the patients after- wards, and usually got them well. And the trustees? If they existed, we saw them not, though aware that they made all those wonderful things possible. They, we felt sure, were only interested in the cost of a bed and its occupant per diem, not why it was that Martha survived her operation while Mary didn't; that Patrick's hernia recurred while Michael's didn't—not how these things might be done better, but only in the numbers of Marthas and Patricks and others the hospital took in and evacu- ated each year. They were the Bee Masters, we the Workers, and it is little to be wondered at, therefore, that to us as to successive generations of house officers, the orderlies, the nurses, the servants and minor officials continuously here were what, even more than the staff, according to our view, gave personality to the hospital." Bowman and his aids visited 692 hospitals in 1918 and the

12 Cushing, Harvey: The Personality of a Hospital. Boston M. and Surg. 1.,185: 536, 1921. Fellowship of Surgeons 221 same number in 1919. Of 671 hospitals of 100 beds or more visited, 264 held regular staff meetings; 301 treated patients after a physical examination was made and recorded. In the remainder there was no evidence whatever of a preoperative study. In October of 1919, the meeting of the College was held in New York. The first list of approved hospitals had been printed and was to be released at the hospital conference to be held in connection with the Clinical Congress. The task of preparing the list had been stupendous. Only 89 out of the 692 hospitals investigated could meet completely the most simple requirements. The showing was so unsatisfactory, with its many embarrassing omissions of prominent hospitals throughout the country, that on the night before the conference was to be held the Regents decided to suppress the printed report. Copies of the report, which were to have been distributed and which named the hospitals, were destroyed. Only the number of approved hospitals among those surveyed was announced. The names of the hospitals were omitted. The results shocked doctors, hospital administrators and trustees into action and made possible the announcement by the Board of Regents of a minimum standard for hospitals which could be a goal to seek. On December 20, 1919, the Board of Regents adopted the program for hospital standardization, with the minimum standard, presented by John Bowman.° This program provided that the doctors in a hospital have a staff organization which would require for membership that the individual be competent in his field of medicine and of worthy character and ethics. It specifically provided that the division of fees, under any guise whatever, be prohibited. The staff of doctors should adopt rules, regulations and policies which would insure the best possible service to the patient. Staff meetings should be held and the clinical experiences of the staff should be reviewed at stated intervals. Ob- viously, the way to do this was to provide accurate and complete See Appendix, Chapter 6:1. 222 Fellowship of Surgeons case records for all patients treated in the hospital and to make them accessible for evaluation. Each hospital to be approved would have to provide laboratory facilities for the study, diagnosis and treatment of patients. During the year, the number of hospitals approved had risen to 198 of the 692 surveyed. In 1920, this number had risen to 407; over one-half of those inspected had met the requirements. The College of Surgeons had distributed thousands of pamphlets giving detailed explanations about the use of patients' records. Blank forms were suggested and sent to hospitals so they would have a point of departure in initiating their own records. Twenty odd meetings of hospital trustees, superintend- ents, nurses, county medical societies, chambers of commerce and business men's associations were held. In September of 1919, the American Conference on Hospital Service was held and the chairmanship of the committee to standardize hospitals had been voted to the College of Surgeons. There were many heated discussions among the Regents, Martin and Bowman concerning the method of obtaining en- forcement of the minimum standard which had been proposed. It became a question of publishing the names of the hospitals which did or did not meet the requirements set down. This would only carry the weight of the prestige which had been generated by the interest which the American College of Sur- geons had taken and the helpfulness which its representatives had shown. Could a certificate of approval be awarded which could then be revoked if the hospital in question failed to maintain its standards? Many of the Regents were becoming lukewarm in their support of the hospital standardization program, believing that any disciplinary action on the part of the College would be highly unpopular and was beyond its function. Besides, more money was needed to finance the program which was becoming more and more expensive to keep in operation. Again, the Regents found it necessary to interpret and explain in detail the pledge which Fellows were required to sign against fee-splitting. They shortened the declaration and lengthened Fellowship of Surgeons 223 the explanatory notes of guidance. Salaries paid to regularly employed technicians and assistants did not constitute division of the patient's fee. Commission arrangements with pathological and x-ray laboratories and commissions received directly, or indirectly, through the sale of splints, optical goods, medicine or any apparatus would, on the other hand, be violations of the declaration. The Regents appointed a committee of three to consider resignations from Fellowship and report them to the Board for their action. Five such resignations were presented at the De- cember 20, 1919, meeting of the Regents. All involved the basic question of fee-splitting. It was decided to approve a plan which Franklin Martin had submitted which would allow the Fellows in states and provinces to establish sectional clinical meetings for the Fellows and their guests only. Martin, supported by William Mayo, proposed a closer affiliation between the surgeons of South America and those of North America by stimulating the interest of the South American surgeons in becoming Fellows of the College. Five thousand dollars was appropriated for "legitimate expenses" of such organizational work as might be necessary. As they had in the beginning, the Regents again became concerned and somewhat confused in their thinking about the payment of Fellowship fees and dues. They had objected originally to the assessment of dues. Finney had said, "Why should dues be paid if one belongs to a College?" All subscriptions of less than $500 to the Endowment Fund of the College were canceled. The amounts of less than $500, which had been paid on the endowment pledges, were transferred to the balances due on the Fellowship fees and annual dues. Fellows in this latter category were to be considered on the same basis as those who did not subscribe $500 to the Endowment Fund. Finally, a committee of three was appointed to clarify the entire situation of adjustments in payments to the College presumably both for the instruction of the Regents and the Fellows. 224 Fellowship of Surgeons Martin proposed that Surgery, Gynecology & Obstetrics become the officially named journal of the American College of Surgeons. The journal was prospering and its publisher agreed to devote an average of eight pages a month to the affairs of the College. Seven of the 14 members of the editorial board, all of whom were required to be Fellows of the College, would be members of the Board of Regents. The Regents accepted the proposal without dissent. Martin had completed a tour of Great Britain and western Europe following the cessation of hostilities and was full of ideas about how the medical profession could contribute to the future welfare of the world. All international medical organizations had been disturbed by the World War and were in need of readjusting their relation to the countries of central and western Europe. For the first time in history and probably, Martin thought, for the last time in generations, an opportunity was at hand to permit the creation of common standards for Fellowship and scientific activities and for the elevation and stabilization of medicine on the highest possible plane. The Regents recorded their unanimous approval of an effort to combine international associations of the important branches and specialties of medicine into a World Congress of Physicians and Surgeons. Such an organization would promote the highest ideals of medicine and strengthen the bonds of friendship between members of the medical profession of all of the participating nations. Out of the Paris peace conference, Woodrow Wilson had returned with the treaty of Versailles and his plan for a League of Nations. The newspapers were filled with the accounts of the struggle between the President and Henry Cabot Lodge to obtain ratification of the treaty and acceptance of the League. It seemed appropriate that the medical profession should take similar action within its own field. Uppermost in Franklin Martin's mind was another matter which he alone could bring to a successful conclusion. This concerned the permanent home for the College. The death of John B. Murphy had resolved the debate within the Board of Fellowship of Surgeons 225 Regents as to the location of the College headquarters. Cer- tainly, the promise of an initial gift of $100,000 by Murphy's widow and his daughters to a memorial tipped the balance in Chicago's favor, in spite of the arguments which Franklin Martin had advanced initially against his own city. He had interested the commissioners of the South Park District to look with favor upon granting a location on the lake front for a memorial building. Roger Sullivan, the boss of the Democratic party in Chicago and Illinois, and John P. Hopkins, an influential attorney, both Catholics and admirers of Murphy, had sponsored the formation of The John B. Murphy Memorial Association. The war had restricted efforts toward fund raising and the most enthusiastic backer, Hopkins, died. The attorneys for the Park Commission asked for a brief outlining the reasons why the American College of Surgeons should be entitled to such a grant of land and the legal steps which would justify the Commission in making such a grant. The attorney for the College, Frank Crozier, did make an attempt to prepare the brief but finally advised Martin that the legal difficulties were too great to be overcome. On the advice of Sullivan, the question was referred to Silas Strawn and John P. Wilson, shining lights in the legal profession of Chicago. They agreed that although it appeared that the South Park commissioners favored the idea, a legal method of accomplishing the grant of land could not be found. Martin then began to search for a site which could be purchased, one preferably with a building upon it which could house the activities of the College until funds had accumulated to carry out all of the plans which he had in mind. It would have to be in a prominent location, afford a future opportunity to purchase property surrounding it and provide immediate space for the erection of the monument to Murphy which would house a library, the museum, which was George Crile's fondest dream, and a meeting place for the convocation. Three locations seemed to fit these specifications. One was at Ohio and Michigan Avenue, another at Dearborn Street and 226 Fellowship of Surgeons Delaware Place and the third at Erie and Cass Streets. Mrs. Murphy was in favor of the site on Michigan Avenue, but the price of the property was set at $350,000. Roger Sullivan had cooled in his enthusiasm for the memorial fund, pointing out that Murphy had been dead for three years. The intervention of the war, which had postponed fund-raising activities, had been a serious blow to the plans. In June, the Regents had listened to the recital of the negotiations and plans by Martin and had vigorously encouraged him to proceed to establish the College in a suitable permanent headquarters building in Chicago. William Mayo stopped off in Chicago on his return from the meeting in Atlantic City and urged Martin to take the Nickerson house and property located on the northwest corner of Erie and Cass Streets. The three-story stone house and stable-garage occupied 150 feet on Erie Street and 109 feet on Cass Street. 13 At the time of completion in 1883, it had cost Samuel Nickerson, the banker, $450,000 and three years to build. It contained a massive marble staircase, a marble-paneled entrance hall and was trimmed with beautiful oak, walnut and mahogany woodwork.° Nickerson had sold his house to Lucius Fisher in 1900, and $50,000 in improvements had been added. The house could be used for the offices of the College and the stable-garage could be torn down and the space used for the memorial building. The McCormick family houses occupied the four corners of Erie and Rush Street just a block east. Mayo agreed enthusiastically that the price of $100,000 was a bargain. On July 1, 1919, A. J. Ochsner, Franklin Martin and John Bowman obtained a 45-day option on the property. Martin began immediately to attempt to raise the money for the purchase. The Endowment Fund had become a respectable one of $500,000, but there was no Building Fund. The $100,000 purchase price was, in fact, the value of the land alone. The

13 Later Cass Street was named Wabash Avenue, its direct continuation north of the Chicago River. See Appendix, Chapter 6:2. Fellowship of Surgeons 227 neighborhood was then in the process of transition from the most exclusive residential district of Chicago to a business, hotel and apartment building area because of the building of the new bridge over the Chicago River and the opening of Pine Street, which was to become Michigan Avenue. August 15 was the deadline for exercising the option and redeeming the $5,000 deposit. The money had to be raised independently of the Murphy Memorial Association. The property would eventually provide an administration home for the College and afford space upon which to erect a memorial building to house a museum, library and all of the other many attributes of a real College of Surgeons. The financial goal was divided into two parts; $75,000 was to be obtained from the wealthy citizens of Chicago and $25,000 from Fellows of the College who lived in Chicago. Martin took his plan to the Association of Commerce with the idea that perhaps they would provide the money as a Chicago commercial enterprise. This bold request evidently impressed the executive committee and, although they did not provide the money or actively raise it, the secretary of the Association presented the matter to the philanthropic advisor of Julius Rosenwald. Martin was told that it was possible that Mr. Rosenwald might provide the entire amount and that no one was more suited to present the matter to him than Martin himself, who had sat with Rosenwald on the Advisory Commission to the Council of National Defense. Martin found Julius Rosenwald an interested listener who seemed to be impressed with the work of the College of Sur- geons and the credit which would come to Chicago to have its headquarters located there. Martin asked him outright for the entire $100,000." Rosenwald had had considerable experience with requests for large gifts of money. He said that he did not think it would be a good thing for the College if he gave the entire amount and he wasn't sufficiently interested in the proposition personally to do so. However, he said that he would be one of a group to contribute and would personally assist in 14 Excerpt from Franklin H. Martin's diary. 228 Fellowship of Surgeons getting others to give. Martin had taken the first step and was encouraged by Rosenwald's promise. The greatest assistance came from E. B. Butler of Butler Brothers, an old friend of Martin's and a man prominent in the business world of Chicago. Butler suggested that Martin ask 15 men to give $5,000 each, since he had guaranteed that the remaining $25,000 could be obtained from the Fellows of the College in Chicago. Butler made out the list of prospects, putting his own name at the top. Martin went to see James Patton, the wheat king, and Frank Logan, a manufacturer, who agreed to contribute. Then he arranged a luncheon for the prospects at the invitation of William J. Mayo, the President of the College. Tele- phone calls followed the mailed invitations and a full attendance seemed assured. On the morning of the luncheon after Mayo had arrived from Rochester, John J. Mitchell, J. Ogden Armour, Louis F. Swift, Eugene J. Buffington, Patton and others tele- phoned their regrets. State's Attorney Maclay Hoyne had suddenly called a meeting for the same hour to discuss the race problem in Chicago. Frank Logan and Julius Rosenwald came to the rescue after Mayo and Martin had talked about the College during the luncheon. Pledges of $30,000 resulted, with Rosenwald, Patton, Logan and Swift giving $5,000 each. By this time, Martin had received enough encouragement and education to realize that the fund raising would have to be done by his personal solicitation. The State Street Retail Stores Association subscribed $5,000, but the hotel association turned him down. The Fellows in Chicago quickly subscribed $17,000 in response to an appeal by letter. On August 14, the day before the option expired, there was a deficit of $29,000 with a large number of good prospects in sight. There was money in the College treasury but the Regents had stipulated that the site which they had agreed to accept must come to the College as a gift from the citizens of Chicago. Not a cent of the purchase price should come from the funds of the College. Fellowship of Surgeons 229 Martin asked A. J. Ochsner if he would sign a note with him for $29,000 so that the option could be exercised. They would keep on soliciting and raising the money from laymen and Fellows. Ochsner agreed and notice of the purchase of the property was given. Six months later, Ochsner and Martin still needed $11,000 to pay off their obligation and this was obtained within the year. Title to the property was taken and it was rented from August 15 to March 1, 1920, for a sum in excess of that which the College was paying for its quarters at 25 East Washington Street. As Franklin Martin confided in his diary, "Everyone was perfectly delighted." Well they might have been. At last, seven years after the idea of a College of Surgeons had been proposed, a building and property situated in the rapidly growing near north side of Chicago provided permanency. This was tangible evidence that the American College of Surgeons existed. From its home the work of pursuing the ideals of the elevation of the standards of surgery and hospitals could be undertaken with dignity. CHAPTER 7

S THE STATURE of the American College of Surgeons increased, new areas of responsibility and influence arose. TheA interest which the College had developed in the program to raise the standards for hospitals was the springboard which had catapulted the College on to the national scene. The Carnegie Foundation was impressed with the initial efforts of the College in the hospital standardization program. In May 1920, the Foundation made a grant of $25,000 to the College annually for three years, in addition to its initial grant of $30,000, to support the work. It was necessary for the Regents to find an equal sum to match the grant each year. The Regents were enthusiastic as they came to realize that their efforts had borne fruit in two directions. Hospitals were vigorously taking steps to raise their standards of operation and the clinical records of the professional work of candidates for Fellowship had already improved a hundredfold. A month after the Carnegie Foundation had made its second grant to the College, the House of Delegates of the American Medical Association formally changed the name of the Council on Medical Education to the Council on Medical Education and Hospitals. In 1919, the American Hospital Conference was organized through the efforts of the American Medical Association. Meet- ings and discussions were held; however, little had been accomplished. The Conference was designed to be an annual clearing house to agree upon the important principles of hospital problems. Thus, it was to be an agent through which reforms could be effected. In the meantime, the American College of Surgeons was investigating hospital conditions with the approval and co-operation of the hospitals. Fellowship of Surgeons 231 At the Montreal meeting of the Board of Regents in October 1920, a letter was received from Dr. Frank Billings, secretary of the Board of Trustees of the American Medical Association and a past-president of that organization. Billings' letter requested the Regents to take action to become a constituent member of the American Conference on Hospital Service. Membership obligated annual dues of $25 and the Board of Trustees had authorized an annual subscription of $1,000 to support the Conference. Upon the motion of William Mayo, George Armstrong of Montreal, the new President, was instructed to write Billings that the College did not wish to become a member of the Con- ference. The Board of Regents felt, the letter said, that the American College of Surgeons had already accomplished a great deal in the standardization of hospitals and in raising the moral standards of surgical work. This had required years of pioneer work, the expenditure of a great deal of time, energy and a considerable amount of money. They believed the matter was fairly well in hand; it was growing and the influence of the College of Surgeons was increasing. The Regents would have to be quite sure that they would be acting in the best interests of the profession and hospital standardization before they would make any change in their program, or take any action which might seem to take from the College the complete control of the situation.

As a result of their visit to several South American countries, Franklin Martin and William Mayo had become convinced that the College could effect a closer affiliation between the surgeons of the two continents and extend its influence upon the elevation of surgical standards. Martin and Mayo saw surgeons at work in their own hospitals. They recommended the names of surgeons to become members of local credentials committees in Peru, Chile, Argentina and Uruguay. These committees, in turn, submitted the names of surgeons as candidates for Fellowship. Acting upon Mayo's and Martin's recommendation, the Re- 232 Fellowship of Surgeons gents agreed to admit approved candidates from South Ameri- can countries as charter members without examination. They were to pay an initiation fee of $25 instead of $100 and annual dues of $25 during the years of 1920 and 1921. Martin and Mayo felt sure that this was a definite step in eventually accomplishing the establishment of the World Congress of Phy- sicians and Surgeons, which could help maintain the peace of the world. Another idea had come from Martin's experiences on the Advisory Commission to the Council of National Defense. It had immediately become apparent to the Commission that steps must be taken to maintain the efficiency of workers and to rehabilitate and restore the disabled in the great industrial army engaged in the manufacture of the essentials of war. Martin had written out some of the goals which should be sought by a committee to be appointed by the Commission. Provisions should be made against unnecessary human waste in industry and society. Preventable deaths and disabilities from accident and disease should be avoided. The sick and injured worker should be restored to full producing power in the short- est possible time. Workers should be maintained in good health, and healthful places in which to work and live should be provided. Samuel Gompers, a fellow member of the Commission, was intensely interested in these proposals and introduced Martin to William Green, Gompers' successor in the American Federation of Labor. At Martin's suggestion, the Board of Regents established a Committee on Industrial Surgery and appointed Edward Martin chairman with the right to choose the members of the committee. Dr. Daniel Z. Dunott, chairman of the Association of Railway Chief Surgeons, was successful in his insistence that the railway executives pass a resolution which stated that their employees should be treated only in hospitals approved by the American College of Surgeons. Edward Martin was jubilant when Dunott influenced the railroad executives to go further and say that if railroads had their own hospitals, such institutions not already approved should be brought up to the standards immediately. Fellowship of Surgeons 233 Edward Martin emphasized that the medical and surgical problems of industry were those of civilian life; that the basis of good surgery for industrial accidents was a sound, fundamental medical education and the long, disciplined training under an accomplished surgeon which fitted men for all surgical endeavors. Each industry, he pointed out, had its own peculiar form of accidents which had to be met by comprehensive surgical knowledge. The medical and surgical requirements of the lumber mills in the west, the oil fields of the south and the steel mills of the east and middle west should be determined. In May 1920, the administrative offices of the College had been moved into the new home at 40 East Erie Street. George Crile spoke often to the Regents about the establishment of a museum, a library and a literary research department. He strongly supported Franklin Martin's suggestions for medical research departments as necessary and correlative functions of a College of Surgeons. In October 1920, a young woman with a knowledge of medicine and experience in library work was engaged to develop a department of literary research.' Martin proudly announced that Mrs. John B. Murphy had donated the library of her late husband to the College. This gave Martin the opportunity to remind the Regents that the administrative home had been a gift from the citizens of the City of Chicago and the Chicago Fellows of the College. The Murphy Memorial Association, he reminded them, was to raise money for a building which could be erected on the College property to contain the museum, library and research departments. Martin was anxious to gain the approval of the Regents to begin the appeal to the Fellows for one-half of the $400,000 goal of the Murphy Memorial Association. He had succeeded in having E. N. Hurley, who had been chairman of the shipping board during the war and whose son had married Murphy's second daughter, become president of the Memorial Associa- tion. John Finney succeeded in postponing such an appeal to

1 Ruth P. Guilder was employed on October 11, 1920. 234 Fellowship of Surgeons the Fellows on the argument that Mr. Hurley was ill and could not be present at the annual meeting of the Fellows to speak.

Constantly, the Regents were concerned with the problem of determining the qualifications in training of the prospective candidates for Fellowship. They had made an encouraging liaison with the newly established American Board of Ophthal- mology. Although they accepted the Board's certificate as evidence of professional training, they insisted that the College insure the candidates' ethical and professional standards of practice. In October 1920, the Regents went so far as to accept successful passage of the examination given by the newly created National Board of Medical Examiners as evidence of a candidate's professional qualifications. It seems obvious now that the Regents were not aware of the aims and functions of this board of examination which dealt with the qualifications of the products of undergraduate medical education. However, it was not long before they understood the purposes of the National Board of Medical Examiners and concentrated their attention upon the American Board of Ophthalmology and the boards which were to follow. The Re- gents had gradually come to the conclusion that they could be of greater help to other groups better fitted to give examinations for fitness in training than to attempt this activity themselves. Their belief was strong that they should concentrate on the ethical and professional practices of their Fellows and to contribute to their continuing education in surgery.

The relationship between the surgeons of Great Britain and the United States had started with the interest of the vener- able Royal College of Surgeons of England in the new College and had been nurtured by the personal experiences of the surgeons of both countries during the war. It was strengthened further when the surgical consultants to the British army presented a gold mace to the American College of Surgeons. The Great Mace, as it became known, was inscribed in memory of mutual work and good fellowship in the World War. It became Fellowship of Surgeons 235 a cherished addition to the gavel which had been presented to the College in 1914.° It was inevitable that sooner or later John Bowman and Franklin Martin would find it difficult to direct the affairs of the College jointly. Bowman had proven himself to be a direct, outspoken idealist who became impatient with procrastination and attempts to appease situations in an effort to gain the ultimate goal. With a zealot's energy he had taken up the banner of the College against unethical professional practices and for the elevation of the standards of hospitals. He had incurred the displeasure of many doctors over the country by his uncompromising speeches; in fact, some of the Regents thought he wished to go too fast in his steps to reform hospitals. These two facts had prompted the Regents to convince Martin that when the war was over, he must give his full time to the College. It was impossible for Franklin Martin to confine his attention to a limited area in the policies of the organization which he had nursed from an idea to a reality. He could and did delegate responsibilities and he was extravagant in his praise for the accomplishments of his associates. He had frequently expressed his admiration for John Bowman's loyalty, enthusiasm and grasp of the purposes for which the College was founded. How- ever, Martin could not share the responsibility of being the spokesman for the policies of the Board of Regents. After serving the College for six years, Bowman was offered and accepted the Chancellorship of the University of Pittsburgh, effective January 1, 1921. He was headed back toward his chosen field of teaching. Bowman expressed his views about the College in a valedic- tory before the meeting of the Board of Regents on December 14, 1920. His remarks reflect some of the difficulty he had in correlating the ideals and goals of the College with the facts as he had found them to exist in the actual practice of medicine. They mirror the obstacles encountered in putting policies into ° See Appendix, Chapter 7:1. 236 Fellowship of Surgeons effect and prove the inherent talents and characteristics of the teacher which Bowman possessed.

. . . The usefulness of the College depends upon its power to project a better future in the science and practice of medicine and to assist in the realization of that future. Such a program of action concerns itself necessarily with principles, not dogmas; with principles to be tried, corrected, expanded, or rejected as, under the test of experience, they prove or fail to prove their value. It necessitates an alert open-mindedness to re-adjust ideas and habits which have hardened through long years into custom. . . . One of the most vital problems, however, with which these men (Fellows) struggle today seems to me especially to demand our clearest thinking. That problem is to cause the purpose or the idealism of medicine to interpenetrate with the scientific or technical side of medicine. . . . In this swift current of action the Fellows sometimes look upon the technical details of surgery as upon details of business; and in performing operations they may confuse self- confidence, vitality, and technical capacity on the one hand, with their intentions, purposes, or ultimate motive of service on the other. Some may even plod through diagnoses and operations with tedium and dislike, failing to put faith or force of conscience into each step which would sweep them on through a life, not colorless, but filled with inspiration. When this confusion occurs, the result is both disappointment and irritation; and then come protests and discontent with the practice of surgery. . . . 2 Bowman said that on many occasions he had interpreted such protests as meanness, but he had been wrong. He had finally concluded that the expressions of irritation were due to the individual's failure to adjust and control customs, traditions, institutions and his own temperament in relation to the requirements of modern surgery. Bowman was as critical and outspoken as his detractors claimed. He said, "The faith of the surgeon does not fuse with

2 From Minutes, Board of Regents, December 14, 1920. Fellowship of Surgeons 237 his technical work; the repetition of operations becomes unillu- minated drudgery; or, as we say, the surgeon fails to make `religion' of his work. This fact is both the chief cause of discontent in the medical profession and the outstanding obstacle to progress." He warned the Regents that the administrative staff of the College could not hasten the elevation of principles and standards by sentimental propaganda or by insistence that men knit higher motives into their work. The Clinical Congresses and the sectional and provincial scientific meetings must continue always to bring scientific information to the Fellows. The conscience of the profession must be stimulated by continued and vigorous prosecution of the hospital standards program, which should be based on the orderly and intelligent use of experience. Both the clinical meetings and the hospital program must be used properly to educate the public and stimulate in them a desire to have the best treatment possible. In these ways, the reaction of the public upon the profession would be swift, wholesome and effective. Bowman's departure created a problem until his successor could be found. In order to counteract the charge that Martin alone determined the policies of the College and the Regents were merely rubber stamps, an Executive Committee of the Regents was appointed to confer with the Secretary-General in all matters of importance in the intervals between meetings of the Board. The committee consisted of the President, the Sec- retary-General, the Treasurer and two other members of the Board. George Crile and Franklin Martin, in particular, were constantly seeking avenues of endeavor which would call attention to the scientific and educational aspirations of the College. The library and a museum were uppermost in their minds. Again, Ernest Codman was destined to play the role of a catalyst in setting off a reaction which was to heighten the prestige of the College. In August 1920, he wrote a letter to each Fellow of the College inquiring if the doctor had in his practice any living patients suffering from bone sarcoma. Were 238 Fellowship of Surgeons the patients under treatment and were there patients who might be considered to have recovered? Joseph Bloodgood and James L. Ewing had joined Codman in attempting to establish a file of all living patients with bone sarcoma in which the diagnosis could be verified properly. They planned to send a duplicate file of all cases to each surgeon who contributed a case report. It was their belief that surgery had failed in the treatment of these patients and that radium should be considered to offer more hope at least in patients when amputation would be too great a sacrifice. Codman meticulously laid down the rules for the reporting of data upon patients. It was important to prove or disprove Bloodgood's contention that when the sarcoma infiltrated the periosteum of the bone, the outlook was bad, but that the giant- cell type of sarcoma which invaded the medulla of the bone carried a good prognosis. No one surgeon had enough experience to state authoritatively the pathological and clinical facts which could guide the treatment of this malignant tumor of bone. The response from the Fellows was a surprise even to the optimistic and idealistic Codman. One hundred seventy-one immediately wrote giving descriptions of patients believed to have had a bone sarcoma. A total of 345 replied that they had not encountered a case but expressed their interest in the project and hoped it might be extended to other surgical diseases. Urged by Codman, the Regents authorized the establishment of the bone sarcoma registry in the American College of Sur- geons on June 7, 1921. An appropriation of $1,500 was made to help the work of the committee, composed of Codman as chairman, Bloodgood and Ewing. The committee would study the history and findings on each case, examine the microscopic slides and then make a diagnosis and offer a prognosis. Cod- man's belief that accuracy in recording and in microscopic diagnosis would show fewer cases of true sarcoma of the bone than claimed was soon proved to be true. It did not take long to show that the College was to serve Fellowship of Surgeons 239 as the center around which another valuable contribution to the care of the patient was to originate. The question naturally arose immediately; should not the College have on its staff a pathologist who could originate similar clinical investigations among the Fellows? This would be a step in the direction to have the College of Surgeons function in research as well as postgraduate education and would place it above the classification of just another surgical organization. The immediate pressing problem was to replace Bowman particularly with respect to his activities in the hospital standardization campaign. Franklin Martin remembered that Harold M. Stephens had spoken about hospital standards at a meeting in Salt Lake City. Stephens had been elected to the bench four years after graduation from law school and spoke about the elevation of hospital standards from a layman's viewpoint. Mar- tin was impressed with Stephen's logical and fluent presentation. The Regents authorized Martin to employ Stephens as director of the hospital activities of the College for a four month period, which was all the time for which Stephens wished to commit himself.3 Stephens traveled extensively with as much enthusiasm and energy as Bowman had displayed but with more diplomacy and a judicial sense of compromise designed to attain the ultimate goal. He believed that the results to be sought in hospital standardization had to be translated into simple terms which the public would understand. He was helpful in resolving bitter differences between the doctors and nursing Sisters of several Catholic hospitals. After four months had passed, Stephens was offered the position of Director of the American College of Surgeons, the post which Bowman had held. He remained another two months working on the hospital standardization program but in Sep- tember 1921, declined the offer to continue and returned to a law practice in Salt Lake City. In addition to educating the profession and the public about Judge Stephens was paid a salary of $12,000 a year, with the offer of a thousand dollar annual increase to $15,000 if he signed a long-term contract. 240 Fellowship of Surgeons hospitals, spade work was being performed by surveyors, employed by the College of Surgeons, who visited hospitals and inspected their facilities and practices. One of the early inspectors who maintained his interest in the program for many years was Frederick W. Slobe, who had just completed his internship in 1919. Four other doctors helped Slobe visit 565 hospitals in the year 1920-1921. All of the southern states and most of the states west of the Mississippi River were covered, and 355 hospitals of 100 beds or more and 210 smaller hospitals were surveyed. Of the 210 smaller hospitals, 27 were found to meet the minimum standards, 37 were questionable and 146 were clearly deficient. Some of the larger hospitals had been visited previously and found lacking. It was encouraging that of the 195 revisited, 75 gained approval. There was no question that an increasing interest in and a more general acceptance of the minimum standards program existed. The program was expanding rapidly and required more qualified surveyors, who in addition to their inspection duties were asked to speak at hospital staff and county medical society meetings. Harold Stephens offered the Regents suggestions based on his six months of intimate contact with the affairs of the College. He urged them to extend the hospital standardization program to complete the survey and classification of all the hospitals in the United States and Canada. Seven hundred hospitals of 100 beds had been surveyed, and 500 fifty-bed hospitals and about 1,000 twenty-five bed institutions remained. Stephens declared it the duty of the Regents to appropriate sufficient money to double or treble the number of surveyors, who should be medical men of greater maturity than those employed in the past. Speakers should be provided from among the Regents, Governors and Fellows. Stephens told the Regents that there should be only one chief executive officer to whom each department head should be responsible. They should not have a Secretary-General and a Director, both of whom were responsible to the Board of Fellowship of Surgeons 241 Regents with neither responsible to the other. He recommended modifications in the credentials system, which qualified surgeons for Fellowship, to secure uniformity, accuracy and justice in the admission or rejection of applicants for Fellowship. All of these suggestions about credentials committees had been provided for previously by actions of the Board of Regents, but apparently Stephens was not aware of these recommendations. He believed thoroughly that the laity should be educated by public meetings with the medical profession. Stephens pointed to the fruitful results of meetings for the public about cancer, goiter and prenatal care. He urged an intelligent co-operation with the press which could produce the most economical, efficient and rapid medium of public education. The Regents never wavered in their determination to build up an Endowment Fund which might be of sufficient size so that the income from it would relieve the pressing need for money to carry on effectively the major purposes of the College. By 1920, the fund totaled $491,000. After many discussions, it was decided to add to the fund 75 per cent of the total received from the Fellowship fees for the five-year period 1921-1926. Another problem, one, in fact, which had been the primary reason for the first meeting of surgeons where they could learn about the advances in clinical and technical surgery, was the postgraduate education of the surgeon. The deficiencies in hospitals in which young graduates could be taught had momen- tarily shifted the emphasis of interest into elevation of the hospitals' facilities and practices. In 1912, only 2,000 internships were available for 4,000 annual graduates from the medical schools, and upon graduation a license to practice could be obtained immediately by passing a written examination. Medical schools sent the students from their doors with a diploma which asserted that they were qualified to practice medicine, a polite fiction which was accepted. At the same time, it was agreed that each of them should serve an internship before beginning practice. In 1913, only the University of Minne- sota School of Medicine required one year of internship before it would grant the degree, Doctor of Medicine. 242 Fellowship of Surgeons From the beginning Franklin Martin had insisted that the medical schools should take the responsibility for the training of their graduates as qualified surgeons following a year of internship. They should be the ones to place the stamp of approval of "qualified surgeon" upon the graduate, who was willing and anxious to spend the necessary time and make the inevitable sacrifices involved in receiving further education in the discipline of progressive responsibility for the treatment and care of the surgical patient. The Regents were unanimous in their opinion that every holder of a state license should not thereby receive a legal permit to perform surgical operations upon his patients. However, it was plainly obvious that state laws of licensure could not be changed. The Clinical Congress of Surgeons of North America and later the American College of Surgeons were the only instru- mentalities by which the medical profession could voluntarily continue postgraduate education for those doctors who aspired to become surgeons. Wherever a human being required the service of a surgeon, there should be a well-trained and qualified surgeon available and a good hospital within easy reach. This, the Regents agreed, was the goal to be sought. To admit Fellows to the American College of Surgeons, it was at once necessary that the Regents adopt a sound standard of surgical training. It followed that accurate data had to be compiled regarding the training of surgeons in medical schools and in hospitals. The training of the internist is also the training of the surgeon; in fact, every procedure in the hospital designed for the welfare of the patient is inseparable from the continuing education and training of the doctor. On October 23, 1919, the Regents appointed John G. Clark of Philadelphia chairman of a committee on postgraduate and research work. As retiring President of the Clinical Congress, Clark had said in his address: . . . The wretched postgraduate instruction of past years should be cast into the discard and courses should be arranged of such essential value that upon their completion by a student his diploma or certificate will be a real and trustworthy evi- Fellowship of Surgeons 243 dence of his ability to practice in that special branch. The six weeks', or even the six months' course of previous years was little less than a "bunco" game, in which the postgraduate student was given a smattering imitation of knowledge, and he in turn went into practice delivering the same deceptive article to

his patients. . . . 4 The next year John B. Deaver said it was but natural that the American College of Surgeons should be heard in matters regarding the training of the surgeons of the future. "Who could influence the future course of education in surgery better than the College?" he asked. The surgeon is in touch with actual conditions and is the man best fitted to deal with the problems of surgery, whether they concern the individual patient or the fundamentals upon which progress in surgery depends. Deaver, noted for his directness and fearlessness, stepped boldly into the furor sweeping the medical profession in favor of the full-time teacher in the clinical subjects of the curriculum of the medical school. . . . I am not questioning the motives of the originators of this audacious movement, but I am watching for its results, not too brilliant thus far and promising less. . . . Without wishing to appear reactionary but with the interest of the profession in mind, I do not hesitate to say that I doubt the wisdom of the present course. . . . The professor of clinical branches should not only be allowed, he should be obliged to be in direct professional contact with the public. The science and art of surgery are one and inseparable. . . . ° With the appointment of the committee on postgraduate education, the interest of the American College of Surgeons in postgraduate training in surgery was inaugurated formally. As Frederick A. Coller said in his presidential address before the American Surgical Association in 1944, "Graduate training in surgery is largely a development since 1920 and has done more

4 Clark, John C.: Three Recent Epochs in the History of the Clinical Congress of Surgeons of North America. Surg. Gyn. Obst., 30:100, 1920. 5 Deaver, John B.: Medical Education. Surg. Gyn. Obst., 34:178, 1922. 244 Fellowship of Surgeons to stimulate original scientific work in surgery in this country than has any other force."

The problem of the Murphy memorial continued to plague the Regents. John Finney had succeeded in postponing serious consideration of the problem at the previous meeting of the Regents, but Martin thought the time had come to make the situation perfectly clear. Walter E. Carr, whom Martin had assigned to the task of running the fund-raising campaign, reported that a total of $500,000 was to be raised. The sum of $200,000, of which $45,000 had been pledged, had been allotted to the College. Mrs. Murphy had pledged $100,000 and the remaining $200,000 was to be secured from other sources. Martin, fully aware of the opposition to the memorial simply because it was to commemorate the name of John B. Murphy, said that he wished to make a few points clear to the Regents. The site and building occupied by the American College of Surgeons were given by citizens of Chicago, 75 per cent by businessmen and 25 per cent by Chicago Fellows of the College. Further, the College had practically outgrown the administrative building in the short interval following its purchase and certainly would be seriously restricted in space within two or three years. It would be necessary to establish a fund with which to build in the near future exactly what the Murphy memorial building would furnish to the College. A hall was necessary for College meetings. More space was required for the library, the literary research department and other activities in education, if the program which the Regents supported was to be carried out and if the College was to accept its responsibility. Unless the Regents made a decision, the Murphy Memorial Association would cease to exist and the money pledged by Mrs. Murphy and others would be lost. Finally, after considerable discussion, the Regents voted to present the matter at the annual meeting of the Fellows of the College with their en-

6 Coller, Frederick A.: The State of the Association. Ann Surg., /20:265, 1944. Fellowship of Surgeons 245 dorsement that the fund-raising campaign be carried on vigorously. The growth of the hospital standardization program was so rapid that it had to be placed under the direction of one individual, experienced in the administration of hospitals and fired with enthusiasm for the contribution which the American College of Surgeons was making. Malcolm T. MacEachem was the general superintendent of the Vancouver General Hospital in Vancouver, British Columbia. A Canadian, he had taught school, received his degree from McGill University Medical School in 1910 and served as resident physician in the Montreal Maternity Hospital. He turned from his training in obstetrics to hospital administration and became the medical superintendent of this hospital in Septem- ber 1911. He acted in that capacity until August 1913, when he moved to Vancouver. On October 25, 1921, the Regents authorized Franklin Martin to enter into an agreement with MacEachem whereby he would devote one-third of his time to the hospital standardization program. He would receive $4,000 for the four months a year which he would spend on the work of the College. Although not a perfect arrangement in accomplishing what appeared more and more to be necessary, it was a step toward bringing doctors into the administrative side of the affairs of the College. Martin reminded the Regents that some time previously he had proposed such additions to the staff of the College and warned them that they must become prepared to accept others. After 20 months of this arrangement, MacEachem joined the administrative staff of the College on June 2, 1923, as Associate Director in charge of the hospital standardization program. As a result of his experiences throughout the following 28 years with the American College of Surgeons, he became an international authority upon matters pertaining to hospital administration.

The colorful John B. Deaver of Philadelphia succeeded to 248 Fellowship of Surgeons the presidency of the American College of Surgeons at the annual meeting in the fall of 1921. At that meeting, Harvey Cushing, the brilliant neurological surgeon, chief surgeon of the Peter Bent Brigham Hospital in Boston and Professor of Sur- gery at Harvard Medical School, was elected President-Elect. He was notified and immediately declined the position. Martin wrote Cushing on November 11, 1921, urging him to recon- sider his decision and appealing to his New England conscience and the high character of his qualifications. Cushing's letter in answer to Martin's reveals a great deal about the great surgeon, artist and author whose irascibility was exceeded only by his charming personality and brilliant intel- lect. At the same time, the letter stated quite clearly the basis for many of the criticisms which were made by the medical profession from a superficial knowledge of the facts and a tendency to damn the entire program of the College of Surgeons because of a valid disagreement concerning one aspect of the aims of the organization. My dear Martin: Your letter of November II has remained on my desk un- answered because I did not quite know what to say. Your appeal to my acquired, if not inherited, New England conscience affects me, I am willing to admit, though I think you considerably misjudge my qualifications for this position. How- ever, it was not upon the grounds of modesty alone that I was led to express my disability. As I told you, I have other obligations which I have assumed which are going to take all my spare time and energy for the next two years or more; and since my illness abroad, I cannot cover as much ground as I formerly could. Furthermore, with full appreciation of all that the College stands for, it has, as you know, a great many enemies, and there are many things about it which are to me most distasteful. I felt sure that if I was to accept the presidency, I was likely to come in conflict with you in some of these matters; and if there is anything in this world that I abhor and desire to avoid, it is controversy. One of the very great, if not the greatest, evil that I see in connection with the College is its publicity, and at the time of the meetings what I regard as the exploitation of patients on Fellowship of Surgeons 247 the part of many members of the College as a part of this publicity. It was to me the greatest evil of the original Congress of Surgeons, as great an evil, indeed, as that of fee-splitting. It was definitely understood the last time the Congress met here that all publications of clinics would be carefully censored. Nevertheless, the papers were full, just as they were at the time of the Philadelphia meeting, of reports which were damaging to the profession as a whole and to individual members of the profession. I was myself victimized, as you may remember, some years ago, after giving a simple clinic before the group who came here to the Brigham Hospital and consequently refused to give any further exercises during the remainder of the week. Doubtless men in different parts of the country look differ- ently on this sort of thing, but I must tell you in all fairness how it strikes many of us in this old community. There are many things other than this that I would like to tell you, but possibly they may as well not be committed to a letter and I had better wait until I can have a frank talk with you, man to man, for I think I know your characteristics well enough to believe that you desire frankness. It is a thing which all people do not give. Since it has been made known that I had been offered the presidency, I have received a number of letters from people who are interested in the welfare of the College no less than ourselves, but who are very severe in their criticisms. It was with these things in view, as well as on the basis of my other obligations and none too good health, that I would have preferred to see someone like George Brewer made president of the College rather than myself, and I adhere to my earlier statement that I think a nominee for the presidency should unquestionably be consulted by the Committee before their choice is made public. I have received letters from W. J. Mayo, Finney and others urging me not to withdraw. In view of what I have said, if you feel that without too great conflict of ideals you and I can serve as Secretary General and President of the College during 1922 and 23, I feel that I may have to accept the position, though I confess to doing so with reluctance. I may, furthermore, have to fail you a good deal in attendance upon meetings, for I am not a good traveler, and have continuously during the school 248 Fellowship of Surgeons year as much responsibility as I can well carry in my present position. Very sincerely yours, (Signed) HARVEY CUSSING Cushing's presidential address was entitled "The Physician and the Surgeon." He stressed the importance of a thorough grounding in general medicine during the training of the young surgeon. This would prevent many unnecessary operations, he said, and would correct many of the evils which exist in the professional relationship between the surgeon and the physician. On the other hand, Cushing believed that a physician without knowledge of surgical principles and objectives applicable to his patients' problems was an incomplete physician. The question of education of the public about the training of surgeons, the nature of operations and the results which might be accomplished was revolutionary. The public knew nothing about the progress in medicine. They had a blind and loyal faith in their family physician whose words were never challenged or explained. Now there would be patients who wished to know about their illness and who was treating them. In particular, Murphy of Chicago and Deaver of Philadel- phia, both with strong, forceful personalities and a flare for the dramatic, were called "publicity seekers." They were stimulating, experienced teachers and their clinics were the most popular. Outside the organization, the College was attacked by those in the American Medical Association who wished to stay aloof from the public. "Treat the patient and tell them nothing" was their motto. Inevitably, those less gifted within the College and those completely outside it made many attempts to join forces to defeat its purposes by attacking its methods of educating the public to become partners in the effort to elevate the standards of surgical care to the patient. There were those surgeons in Boston, a cradle of criticism, who believed in the College and followed the example of Cod- man in suggesting and having adopted a plan which they be- Fellowship of Surgeons 249 lieved was a contribution to the care of the patient. Charles L. Scudder was invited to appear before the Regents in Washing- ton on May 1, 1922, to present his petition requesting the Col- lege to sponsor a study of the treatment of fractures. Scudder said that throughout the United States and Canada the treatment of broken bones was deplorably bad and there was no recognized authoritative statement upon the fundamental principles governing the treatment of fractures. As a result, teaching was at great variance and for the most part unsatisfactory. Following fracture treatment there was a large group of lawsuits for malpractice which were a disgrace to the profession. A new relationship was beginning between employer and laborer which made industry call for improved treatment of the patient to obtain more satisfactory and an earlier return of function. Employers' liability laws, industrial accident boards and insurance companies were demanding better results in order that the laborer could return to his job more quickly. Scudder further reported that no individual doctor attacking the problem alone could accomplish what was necessary. It required an authoritative body like the College of Surgeons to initiate and promote dignified, quiet and effective propaganda of educational reform pointed toward raising the standards of treatment in large and small hospitals. Well-planned teaching of undergraduate and postgraduate students of medicine was essential. As corollaries to such a program, it would be necessary to gather information about medico-legal problems and rehabilitation programs. Education and co-operation of the insurance companies and instruction of the public were required for a successful program. The Regents quickly appointed a committee to present a plan in accordance with Scudder's petition. They were anxious to implement Scudder's suggestions immediately.? On October 24, 1922, the Regents approved a plan to make The original committee to study the treatment of fractures consisted of Charles L. Scudder, Boston, chairman; Joseph A. Blake, New York; William Darrach, New York; William O'Neil Sherman, Pittsburgh; Robert B. Osgood, Boston; Kellogg Speed, Chicago; Astley P. C. Ashhurst, Philadelphia; William L. Estes, Bethlehem, Pa.; and George W. Hawley, Bridgeport, Conn. 250 Fellowship of Surgeons each member of the original committee the chairman of a regional group with authority to name the personnel upon his committee. Three questions were posed for answers from each regional organization: (1) What are the general principles underlying first aid treatment of fractures, including transportation? (2) What are the means by which these principles may be put into effect? (3) Make definite recommendations as to the equipment of ambulances and first aid agencies, including hospital receiving wards, in an effort to establish standardization. As a result of the proposed study, the committee told the Regents they hoped to formulate certain simple methods of treating common fractures and eventually write a manual of treatment for the guidance of teachers in all medical schools. The Regents also appointed a committee to investigate the use of radium and x-rays in the treatment of malignant tumors and specified that the nucleus of the committee consist of those men appointed by the American Surgical Association, with such additions as the Regents might wish to make. 8 Two thousand dollars was appropriated to help with the study, and another enthusiastic supporter of the College, Robert B. Greenough of Boston, was named chairman. The first project undertaken by the latter committee in May 1922 was to attempt to secure reliable data in regard to the results of treatment of cancer of the cervix of the uterus. The committee proposed to secure reports upon patients treated in established clinics by operation, roentgen rays or radium in such detail that results might be compared and summarized. Only those patients who had been followed over a period of at least five years after treatment, and in whom microscopic veri-

8 The Committee to Study the Treatment of Malignant Diseases with Radium and X-rays consisted of Robert B. Greenough, Boston, chairman; C. F. Burnam, Baltimore; G. W. Crile, Cleveland; William Duane, Boston; J. M. T. Finney, Baltimore; H. K. Pancoast, Philadelphia; and F. C. Wood, New York. H. R. Gay- lord, Buffalo; A. J. Ochsner, Chicago; C. Jeff Miller, New Orleans; C. H. Peck, New York; John G. Clark, Philadelphia; C. H. Mayo, Rochester, Mimi.; and A. Primrose of Toronto were associate members of the committee. Fellowship of Surgeons 251 fication of the diagnosis of cancer existed, would be used in the study. Thus, three clinical investigations had been initiated in addition to the hospital standardization program. Codman submitted a meticulously documented financial report of the expenditure of the $1,500 which had been appropriated for the use of the bone sarcoma registry. In the first six months of its study, Codman's committee had concluded that there were not more than 500 patients with true osteogenic sarcoma in the United States. The report pointed out that there were at least two supposed bone sarcomas to one true instance of the tumor. Envelopes with serial numbers containing the history of the patient, x-ray prints and microscopic slides were sent to pathologists for their opinions. Such distinguished pathologists as Wright, Ewing, Bloodgood, Mallory and Wolbach came in for a verbal spanking from Codman when he reported that each of them had used a different name for the same tumor, an absurdity in nomenclature which the committee hoped to correct. Codman asked the Regents to urge the Fellows to register every living patient in whom a diagnosis of bone sarcoma had been made. He added that the committee would be happy to continue to serve upon the request of the Regents accompanied by more money to continue the study. The Regents wished to lend the influence of the College to improve the laboratories in hospitals. They secured the interest and help of pathologists who were not Fellows of the College of Surgeons. Ludwig Hektoen of Chicago, M. J. Rosenau and L. B. Wilson of Rochester, Minnesota, Francis Carter Wood of New York and Surgeon General E. R. Stitt were the committee members appointed by the Regents. At first, only Rosenau and Wood met with Squier, Peck, Crile and Martin. The report was a helpful one, although it did not take into account the fact that the small hospitals could not meet the proposed standards. The important point submitted was that the director of a clinical laboratory in a hospital should be a graduate of a medical school and that all 252 Fellowship of Surgeons interpretations of laboratory data should be made by doctors trained in the branch of work to which the data pertained.' It was necessary to ask the committee to meet again to report on a broader and more detailed plan which could be adapted to improve the existing conditions in all types of hospitals instead of prescribing only the ideal which was the goal to be reached.

In 1919, the idea of holding meetings of the Fellows in sections over the country was proposed to Franklin Martin by an enthusiastic Founder member of the College, John Wesley Long of North Carolina. Clinical meetings were authorized by the Regents "to promote within the individual states and provinces, the purposes for which the American College of Surgeons was founded."" During the first year the program consisted of clinics on the mornings of two days, two scientific sessions and a meeting in the evening which was open to the public. One of the scientific sessions was replaced later by a hospital conference. The success of the meetings was apparent from the beginning. Attendance was doubled the second year. The meetings open to the public were addressed by laymen as well as doctors. Some of the subjects presented by Fellows of the College were the purposes of the American College of Surgeons and their relation to the public; better hospitals; means by which the public could aid in reducing the mortality of cancer; the economic value to the community of prenatal examinations; the relation of the hospital to the community; what the public should know about disease; the work of the American Society for the Control of Cancer; the public's debt to medicine; and the importance of the public's early recognition of goiter. There was open opposition to the innovation of doctors addressing laymen in a public meeting, and attempts were made

9 At the time, Mercy Hospital in Chicago employed a former orderly to interpret x-ray glass plates, and Wesley Memorial Hospital in the same city employed a nurse in the same capacity. 10 Summary of Group Meetings of State and Provincial Sections of the Clinical Congress of the American College of Surgeons, 1920 to 1922. Surg. Gyn. Obst, 35:248, 1922. Fellowship of Surgeons 253 to stop this type of program which had been initiated in 1913 by Thomas Cullen when he spoke about cancer to a lay audience at the Clinical Congress in New York. As these sectional meetings went on, however, the public became cognizant of the program to improve hospital care. They were gradually learning that many of the scientific aspects of medicine contributed to their health. They became aware that doctors were not men of mystery but were human beings and their benefactors. They had heard doctors speak on vital subjects pertaining to public health in simple language based on scientific knowledge and practical experience. Twenty-two sectional meetings were held during the year ending October 1, 1923. Attendance at the meetings to which the public was invited totaled 25,975. The success of the sectional meetings demanded more attention from the administrative staff. Dr. Allan Craig joined the staff of the College of Surgeons on January 1, 1923, and assumed the responsibility of these sessions for doctors, hospital administrators, nurses, laboratory technicians and laymen. 11 Craig asked for the co-operation of the Fellows, when he addressed them at the Clinical Congress, and summarized the purposes which the College hoped to accomplish through meetings with the laity: In a great many instances, what the public gets of medicine and surgery it reads in the advertisements of patent medicines in the press. We are trying to come to the public with a message of good health and good hospital service and thereby establish with the public a more confidential relationship toward our profession." Franklin Martin and William Mayo had been enthusiastic in their report about surgery in South America. The Regents com- missioned Dr. Francis P. Corrigan of Cleveland and Dr. Ed- ward 1. Salisbury of Denver to travel through Latin America " Craig, like MacEachern, was a Canadian and was provincial commissioner for Canada of the Red Cross in Nova Scotia. He was educated at McGill Uni- versity and had devoted himself to the treatment of patients with tuberculosis. Later, he organized public health activities under the Red Cross organization. 12 From Minutes, Annual Meeting of Fellows, October 25, 1923. 254 Fellowship of Surgeons to evaluate the possibilities of extending the principles for which the College stood to the profession in those countries. Corrigan and Salisbury had their difficulties. The Argentina Surgical Society objected to the wording of the pledge because they considered it a reflection upon their honor. The final draft of the pledge was in Spanish and was more drastic in its condemnation of commercialism in surgery, but it was acceptable to the Argentinian surgeons. In Chile, the committee complained that it had been ignored in granting Fellowships. Bolivia was undergoing a political revolution. The Panamanian Fellows were not a large group but, including the United States Army and Navy doctors, they were strong and enthusiastic supporters of the College. After much hard work, a good start was made in spreading the principles of elevating the standards of surgery in the South American countries. There were many who were convinced that the ideals and purposes of the American College of Surgeons were not fully understood at home and that this lack of understanding was the source of criticisms which seriously disturbed the rank and file of the medical profession and some of the Fellows. John Wesley Long was a man with ideas and a flair for organization who believed in action to educate the doubters. Long discussed the formation of an auxiliary body in each state and province which would be called a Candidate School for Fellowship in the American College of Surgeons. The Candi- date School would have three objects, to spread the propaganda of the American College of Surgeons, to train surgeons and specialists for Fellowship in the College, and to bring about a closer relation between the College and both profession and laity. Long established such a candidate organization in North Carolina, after securing the endorsement of the "state executive committee of the American College of Surgeons and the North Carolina Fellows." The plans stated that these auxiliary bodies, or so-called schools, were to be under the control of the College and fostered by it. However, membership in the Candidate School for Fellowship did not constitute any guarantee what- Fellowship of Surgeons 255 ever by the College that a member would be elected to Fel- lowship.18 Long appeared before the Board of Regents in Chicago on October 23, 1923, in response to an urgent telegram from Frank- lin Martin asking him not to "move further with your organization until you can present full plans in person to the Board of Regents. Any plan accepted by Regents must be applicable to all states and provinces." The Regents listened politely, received Long's suggestions with thanks and referred the matter to the Executive Commit- tee, a smaller group in which Long's eloquence would meet with more logical and practical answers. There appeared to be conflict between Long's ideas and the junior candidate group first proposed to the Regents by Joseph Bloodgood. Some of the Regents wished that the College could devote all of its energies toward the scientific studies which had been started, but fee-splitting and the resistance of some hospitals to elevation of their facilities always appeared cyclically. C. A. Roeder, a Fellow from Omaha, Nebraska, was sued in court by the Nicholas Senn Hospital of that city. Roeder was accused of telling the father of a patient that he would not operate on the patient in the Nicholas Semi Hospital because he preferred to operate at other hospitals which did not permit the splitting of fees. Donald Macrae of Council Bluffs, Iowa, had spoken to the Board of Regents about the difficulties which he and other Fellows were encountering because of fee-splitting in Iowa, Nebraska and adjacent states. The Regents wanted to strengthen the fee-splitting pledge and debated its wording again and again. Judge Harold Steph- ens, who had returned to his law practice in Salt Lake City, was engaged to defend the interests of the College in the suit filed against Roeder. The suit dragged on and cost the College $5,000 for which Judge Stephens gave the Regents the advice that they should not look to the courts as a sensible or fruitful means of attack

13 Excerpt from Minutes, Board of Regents, October 23, 1923. 256 Fellowship of Surgeons upon the problem of fee-splitting. The results of litigation, he said, are too uncertain. There are too many opportunities for technical evasion of the issues and the outcome of the suit is never sufficiently subject to prophecy to make it a wise thing to attempt to solve the problem by a lawsuit. Doctors, hospitals and patients would just have to be educated, Stephens concluded, and it would take a long time. Criticism of the Board of Regents and the administration of the affairs of the College came simultaneously from two new sources in June 1924. The idea for the Clinical Congress of Surgeons of North America had come to Franklin Martin when he learned about the Society of Clinical Surgery and its semiannual clinical meetings. He gave all credit to that organization, saying that he applied the idea to a large group instead of to a select few. On June 12, 1924, Dean D. Lewis, an associate of Arthur Dean Bevan at the Presbyterian Hospital in Chicago, presented a petition which had been passed by the Society of Clinical Surgery at its meeting in Rochester, Minnesota, on June 6.° This society of teachers of surgery in the medical schools endorsed the aims and objects of the College but conveyed a number of suggestions to the Board of Regents. The petition stated that the number of Fellows admitted each year should be reduced immediately and those admitted should be distributed as needed in the country, provided that they met the requirements of the College. Methods of examining candidates should include more rigid tests as to the character, training and intelligence of the applicant. State credentials committees should be instructed that the terms "Rejected" and "Not Recommended" are not synonymous. Finally, the committee from the Society of Clinical Surgery, consisting of Lewis as chairman, George J. Heuer, John L. Yates, E. Starr Judd and E. Wyllys Andrews, said that the proselyting of members should be stopped. Those Fellows who applied for admission were ° See Appendix, Chapter 7:2. Fellowship of Surgeons 257 more valuable, they thought, than those who were invited to become Fellows. At the same meeting of the Regents, a longer and more detailed petition was presented by M. B. Clopton of St. Louis on behalf of the Eclat Society. The petition was identical to that of the Society of Clinical Surgery, no doubt because many young surgeons held dual membership in the two groups. The Eclat Society arose as an outgrowth of the close association in France of several young surgeons. The requirements for membership, according to one of its members, were that the candidate should have served at the front, should have been scared and should hold a rank no higher than captain. Mem- bership was limited to 50, and 32 charter members were elected. Arthur W. Elting of Albany became president, Dean D. Lewis of Chicago, vice-president, and Burton J. Lee of New York, secretary and treasurer. Only one meeting would be held annually, and it would be of a social rather than a scientific or professional character. There was only one honorary member, and J. M. T. Finney, who had been the Chief Surgical Consultant to the American Expeditionary Forces, was named. According to the Society's secretary, "It stands for something choicer and finer than any other group or organization of medical men in this country." One of its members has said that the society had no aims to interfere with or dictate to other surgical organizations. In commenting upon the activities of the Eclat Society, he said that it was by chance only that its members matured in surgery at the same time and that, in succession, five were elected to the presidency of the American Surgical Association." These were young surgeons, all well-trained and active teachers in departments of surgery in medical schools. They regarded the Board of Regents as conservative old men who were being hoodwinked by Franklin Martin and served only as a front for his policies. Many of them, privately and publicly,

14 Personal communication. 258 Fellowship of Surgeons were convinced that the Board of Regents needed an infusion of young blood. The petition of the Eclat Society was read personally to the Board of Regents by Clopton, who was accompanied to the meeting by Lewis and Heuer. It was read and discussed item by item.° Upon Martin's motion, the Regents decided to make one answer to the two petitions, since the contents were similar. They proposed to send copies of the petitions to each Fellow accompanied by a detailed answer to be written by Ochsner, Charles Mayo, Crile and Squier. The Eclat Society petition professed the signers' accord with the original conception of the American College of Surgeons to raise the standards of the profession, moral as well as intellectual, by "disinterested and unselfish efforts" and to foster research and to educate the public to the idea that there is a great difference between an honest, conscientious and well-trained surgeon and the commercial operator. Their exceptions were several. They emphasized a widespread impression that in the membership of the College were men who were fee-splitters or who were reputed to pay commissions to referring physicians. They charged that nothing had been done to get rid of such Fellows. In fact, the petition said that men who had been rejected by the state credentials committees were eventually admitted to Fellowship. Joseph Bloodgood's plan for a junior candidate group was severely criticized, although it had not been adopted by the Regents. It was claimed by the petitioners that Fellowships were granted to immature surgeons and the Clinical Congress was held for the sole purpose of educating these surgeons. The junior candidate group advertised the fact that they were Fellows, a practice which could only be controlled by stopping the junior candidate plan. The minimum standard for hospitals was not enough; the standards should be raised. However, none of the petitioners had taken part in the inauguration of the program. The strongest criticisms were directed at Franklin H. Martin • See Appendix, Chapter 7:3. Fellowship of Surgeons 259 and the failure to issue a satisfactory financial statement. The Director General, the title which had just been given to Martin, was said to be arbitrary in his actions. Since much of the management of the College was in his hands, it was charged that he dictated what should be done rather than executed the policies developed by the Board of Regents. This charge drew the anger of the Regents. They had heard themselves called old and stodgy, and now it was charged they said and did only what Martin told them to say and do. The claim that they had permitted financial irregularities could easily be proven a falsehood and this did not disturb them greatly. The committee of the Regents appointed to prepare the reply was instructed to waste no time and to publish the petitions and the answer in a pamphlet to be distributed to every Fellow of the College. In the preamble to their concisely argued rebuttal, the Re- gents said that the petitions contained topics of fact and topics of policy, according to their analysis, and would be treated in such a manner." The allegation that no satisfactory financial statement had ever been issued came first in the reply. It was pointed out that all of the books, accounts and financial affairs of the American College of Surgeons had been submitted in detail to the annual scrutiny of Ernest Reckitt & Company, a reputable firm of public accountants and auditors in Chicago. Each year at the annual meeting of the Fellows of the College, the Treasurer read his report of the certified, itemized income and expenditures of each department of the College. At each meeting of the Execu- tive Committee and the Board of Regents, the Treasurer presented a financial statement. Once before, the Regents had been forced to appoint a committee, on which Arthur Dean Bevan sat, which corroborated the fact that an auditing firm had certified all of the financial transactions of the Clinical Congresses and the College. Al-

15 From the Minutes of the Board of Regents, June 12, 1924, which contain the complete copy of the Regents' reply to the petitions of the Society of Clinical Surgery and the Eclat Society published and distributed on July 15, 1924. 260 Fellowship of Surgeons though the books of the College were open for the inspection of any Fellow at any time, the Board of Regents said that in view of the interest expressed in the financial statements, they had directed that thereafter a copy of the Treasurer's annual report would be mailed to each Fellow. The assertion that undue and distasteful publicity was permitted at the annual Clinical Congress obviously centered on individual Fellows whose names appeared in the reports of the press. The Regents had encountered this charge before. To control the comment by the press upon scientific matters of public interest which were introduced at the Clinical Congress, and realizing they could not prevent newspaper comment, a committee on publicity had been appointed from the Fellows in the city holding the Congress. The committee was empowered by the Regents to authorize publication of such matters of interest, and in such a manner, as would be consistent with professional propriety. The Regents stated that they had received full co-operation from the press since the inauguration of this plan which they did not realize then would develop into the closest relationship between any medical organization and the press in the United States. They regretted that specific instances of abuse had not been called to their attention. Another charge could have been investigated easily before it was made but, as is often the case, a loosely made assertion by repetition soon is accepted as fact. Candidates for Fellowship, it was said, were accepted after being rejected often more than once by a state credentials committee. An examination of the credentials records of the College disclosed, said the Re- gents, that from its organization only three candidates had been accepted as Fellows out of a total of 7,037 who had been rejected by the local committee. These three instances occurred eight years previously, and each had been acted upon individually by the Board of Regents in whose hands rested the power to overrule a local credentials committee. When they came to the accusation that Franklin Martin was arbitrary in his actions and that since much of the responsibil- Fellowship of Surgeons 281 ity of management of the College had fallen upon him, he had dictated what should be done rather than to follow the advice of the Board of Regents in developing and maturing its plans, the Regents' reply reviewed in minute detail the bylaws of the College. The responsibility of the general management rested in the Board of Governors which, in turn, imposed duties and responsibilities upon the Board of Regents whom they elected. The Executive Committee, consisting of the President of the College, elected by the Fellows, the Director General, the Treasurer and four Regents met frequently between the semiannual meetings of the entire Board of Regents. It was not contemplated by the bylaws that the Regents should devote their full time to the work of the College. They received no compensation either directly or indirectly. It was obvious that the American College of Surgeons needed a chief executive officer with "pronounced qualities of vision, initiative and executive ability," who would devote his entire time to the organization for an adequate salary. There was no qualification in the Regents' answer that Mar- tin was such an executive and that he had exercised his qualities loyally, wisely and impersonally in the interests of the Col- lege. That he had been permitted, or had attempted, to substitute his judgment for that of the Board of Regents on matters of policy was untrue. The Regents' statement emphasized that the meetings of the Board of Regents, the Executive Commit- tee, the Board of Governors and the Fellows were open to all Fellows of the College, if they wished to attend and make observations at first hand. Many of the older Fellows, among them Harvey Cushing, had objected to the Clinical Congresses. Particularly, they were opposed to the surgical clinics during which the surgeon worked under tension and the operating room was crowded with visitors asking questions and milling about. In their opinion, the patient ultimately was the one who suffered. The petitions claimed that the purpose of the Clinical Con- gress was to educate immature surgeons who were granted Fellowships in the College. After graduation from medical 262 Fellowship of Surgeons school, seven years experience in surgical training and practice was required to become a Fellow. This was a minimum requirement only, which seemed to the Regents to offer proper assurance of training and experience to the public. The Clinical Congress was an exchange of knowledge which continued the education of the surgeon. Joseph Bloodgood of Baltimore had first suggested the creation of a group of junior candidates to the Regents, and the principle finally had been accepted. It had been discussed many times, as had the methods of implementing the idea. The Re- gents had been forced to keep the enthusiastic John Wesley Long from progressing too rapidly in his efforts to interest young surgeons in the ideals of the College. The petitioners disapproved the opportunity which they said was given the junior candidate group to advertise they were Fellows of the American College of Surgeons. This assertion, said the Regents quite bluntly, was not correct. The names of the junior candidate group were published in a separate pamphlet furnished only to the candidates and the Fellows of the College. The answers to any one and all of these factual topics contained in the petitions could have been obtained, if the fault- finders had made an effort to get the facts before categorically making charges. Their entire case, which included some constructive suggestions as to policy, had been weakened by misstatements which could easily have been proven right or wrong had they made the effort. Involved were personalities and emotions which apparently were descending by inheritance from the older teachers of surgery, opponents of the College from the beginning, to their younger pupils. These were evidently so strong that Arthur Elting, president of the Eclat So- ciety, sent in his resignation to the College before his society's petition was presented, let alone answered. The Regents' reply then came to matters of policy about which there could be an honest difference of opinion and upon which the Regents themselves were not always unanimously agreed. It was true that the viewpoint of the younger surgeons in the country was lacking among the Board of Regents. How- Fellowship of Surgeons 263 ever, the Board constantly asked who there was among the young surgeons who would devote himself unselfishly and enthusiastically to the aims and purposes of the College; one who had logical reasoning powers and judgment, neither of which virtue they believed was exhibited by the signers of the petitions. The petitioners believed that the junior candidate group should be abolished. It had been Bloodgood's original argument that the junior candidate group would offer an opportunity for the young men, who had not yet had seven years surgical experience in training and practice, to be brought directly within the sphere of influence of the College. Professional habits, particularly those within the field of ethics, Bloodgood said, are ordinarily formed within the first few years after graduation from medical school. The Regents had agreed that it was a matter of duty for the College to extend its influence among young men in the early years of their training. The Regents held that any minor defects incident to these purposes were overshadowed by the purpose of instilling into these young men the principles and standards required by the College for ultimate admission to Fellowship. The petitions implied that the American College of Surgeons was emphasizing the quantity of work done in hospitals rather than the quality and that the minimum standards of the hospital standardization program should be raised. It was said that the hospital inspectors were too young to be qualified for their duties. It was charged that hospitals were approved by the College's program notwithstanding the fact that they admitted patients of doctors who split fees. Codman's original proposal, supported vigorously by Edward Martin and adopted completely by the Regents, had emphasized character and quality of service rather than quantity. The slogan "Not for more hospital service, but for better hospital service" was a matter of record. The Regents had debated the ideals of hospital standards time and time again. Each of them knew that practical considerations influenced the rapidity with which the program could be put into effect. Even Codman and Martin, the most idealistic of the originators of the project, had 264 Fellowship of Surgeons been more than satisfied with the progress made in the voluntary acceptance of the program, particularly in view of the total lack of any legal method of enforcing it. Now came the critical suggestion that the Regents were agreeing to a lowering of the minimum standards and the implication that the task was an easy one from the beginning. Experience had shown, said the Regents, that the program would eventually be most successful if all of the hospitals were first brought up to the minimum standards before they were raised further. This did not mean that hospitals were not being encouraged to go beyond the existing minimum requirements. The Regents had agreed with the Associate Director, Mal- colm MacEachem, that recent graduates of the largest and most efficient hospitals were more capable of making inspections, comparisons and reports, which were suitable for purposes of classification, than older physicians who had no active or recent experience in approved hospitals. The final approval of hospitals in the program was made only at the direction of the Board of Regents after receiving the reports prepared under the responsibility of the Associate Director. The inspectors sought only the facts as laid down by the standardization program. The Regents denied emphatically that they knowingly had approved or retained on the approved list a hospital whose staff was composed of doctors who divided the patient's fee. The minimum standard contained a provision "that membership upon the staff of hospitals be restricted to physicians and surgeons who are competent in their respective fields and worthy in character and in matters of professional ethics." In respect to the latter restriction, the practice of the division of fees under any guise whatever was specifically prohibited. In addition, the College required that the entire staff of a hospital seeking approval was required to sign a resolution, or pledge, not to engage in fee-splitting. The Regents admitted that in some instances the pledge was loosely signed and in other cases deliberately broken. However, when there was reasonable assurance that the division of fees was practiced in a hospital, the College refused approval or, if the institution had been approved previously, approval had been removed. The Fellowship of Surgeons 265 Regents pointed out to the petitioners that moral and legal responsibilities were involved in such actions and, therefore, they had to act upon reasonable grounds. Though not contained specifically in the petition, the petitioners later suggested five avenues of improving the quality and ideals of those surgeons accepted for Fellowship and of decreasing the number admitted each year. More rigid tests as to character, training and intelligence should be adopted. A numerical limitation should be placed on the number of Fellows admitted annually; if necessary, admissions should be allocated geographically where surgeons were needed. Candidates rejected by local committees on credentials should not be recon- sidered for Fellowship for from three to five years, except with the sanction of the Board of Regents. Proselyting for members should be stopped, and all Fellows who split fees should be expelled from the College and a public announcement of the dismissals made to the profession. Of all doctors professing to practice surgery in the United States, Canada and foreign countries, only 6,181 were Fellows of the American College of Surgeons. The purpose of the Col- lege was to be a democratic organization so that any worthy and capable surgeon would feel free to apply for admission to Fellowship. A serious and earnest effort had been made to admit only those who were worthy and capable. If the Fellow- ship were limited to a small number, the College would do little more than duplicate the work of special surgical societies such as those the petitioners represented. In order to organize the College, it had been necessary to trust the judgment of the special surgical societies for its initial membership. Inevitably, said the Regents, some became members who were not worthy of the ideals and purposes of the American College of Surgeons. The petitioners, discussing the application of tests for character, training and intelligence, suggested that the medical schools of the United States be authorized to conduct the examination. Franklin Martin had made this same suggestion at the beginning of the College's formation, but it had fallen on deaf ears in the medical schools. They had not accepted the 266 Fellowship of Surgeons responsibility for declaring the qualifications of a surgeon. Even today, the American College of Surgeons is charged with having been dilatory and backward in failing to assume the functions of certifying the qualifications of a surgeon which were appropriated by the American Board of Surgery and other surgical specialty boards of examination. From the first, however, the American College of Surgeons concerned itself with ethical and professional standards in practice. The Regents were of the opinion that numerical limitation and geographical allocation of Fellowships did not constitute a fair and just method. An arbitrary limitation should not be imposed as long as the number of admissions of capable and worthy candidates did not make the membership too large in relation to the entire medical profession. The Regents had previously passed a motion that candidates for Fellowship, rejected by the local committees on credentials, could not be considered again for three years, except upon authorization of the Board of Regents. This would provide for an appeal directly to the Board of Regents in exceptional instances. Proselyting for Fellows was denied briefly and emphatically as a falsehood. In the early history of the College, surgeons of outstanding reputation and ability, whose aid and support were considered necessary for organization, had been asked to become Fellows, but the Regents did not consider this practice to have been sinful. The most difficult problem of all, said the Regents, was to dismiss from the College those Fellows who practiced the division of fees. It was stated emphatically that the suggestion that the Board of Regents knew of Fellows who split fees and did not expel them was completely untrue. It was their moral and legal duty, the Regents said, not to defame unjustly the professional character of any Fellow. It was pointed out to the petitioners that it was difficult to prove legally, other than by his own confession or proof submitted by his accomplice or a patient, that a Fellow of the College practiced the division of fees. Fellowship of Surgeons 267 The minutes of the Board of Regents showed that a number of resignations had been secured because of an infraction of the signed pledge against fee-splitting. However, the Regents did not believe that public announcements concerning the resignations should be made. Future directories of the Fellows of the College would not contain the names of those surgeons expelled or allowed to resign. If, by the suggestion that stress should be laid in the future upon research work, the petitioners merely meant that added emphasis should be given to research work under the auspices of the College, the Regents were in complete accord. The work of the committees on cancer, the treatment of fractures, the bone sarcoma registry and the improvement of hospital laboratories was being expanded as rapidly as funds and facilities permitted. Finally, the Regents called the attention of the petitioners to the fact that the majority of the Fellows of the College were more interested in clinical problems than in pure research by virtue of the fact that they were engaged in surgical practice. Any suggestion that the sectional clinical meetings or the annual Clinical Congress be abandoned would not be accepted by the Regents. They regarded these as among the most useful functions of the College, in which opinion they were supported by the majority of Fellows. A logical, well-briefed, fully explanatory and firm but diplomatic statement from the Regents resulted from the presentation of the petitions. In the rapidly growing organization, with ideals and purposes which could be accomplished only by voluntary participation of its Fellows, it was inevitable that misunderstandings would arise. Opinions upon questions of policy differed widely and the Board of Regents said that it would welcome at all times inquiries on matters of fact and constructive suggestions and criticism on matters of policy. It was a good thing for the Fellows to have such a detailed statement from the Board of Regents, and the necessity to prepare it had a salutory effect on the Regents in that self-examination had been required to compose the reply. CHAPTER 8

Pp HE 'TWENTIES were prosperous years in the United States. I Roads on which an increasing number of automobiles could be driven with a reasonable amount of comfort and safety were rapidly constructed. Buildings were going up everywhere. The tallest building and the largest hotel in many cities today were built during those years. Radio, bath tub gin and jazz had arrived. Wages were stable, as were prices; the output of the workers increased rapidly as did the incomes of the wealthy. The consumption of luxuries by the latter group and the investment of money they did not or could not spend on themselves—non- participation of farmers in the advance of prosperity—the weakness of the trade unions and the lack of organization of workers to deal with the demands of such industries as the steel corporations—all combined to create a serious flaw in the economy of the country. The United States had ceased to be the greatest debtor country in the world and had become the greatest creditor. This forced the country to import far more than it exported so that its debtors could pay the principal and interest which they owed. Foreign debts were forgiven or new loans were made to pay off the old. Corporations were organized to hold stock in other corporations which, in turn, held stock in a third corporation and so on, until pyramids of holding companies were formed. Month after month and year after year, the great bullish stock market rolled on. Conversations in the intervals between scientific papers at medical society meetings centered about the "killings" which smart, businesslike doctors had made in the stock market. Notoriously easy prey for stock promoters, Fellowship of Surgeons 269 doctors made up a sizeable percentage of the customers with new money who were swarming into the market seeking capital gains. Plans to erect a memorial to John B. Murphy progressed slowly, due in part to the confusion caused by the war effort but mainly because of antagonism within the American College of Surgeons to the idea. However, Walter E. Carr, to whom Franklin Martin had given the high-sounding title of "fiscal agent," finally succeeded in obtaining donations of $400,000 from citizens of Chicago and Fellows of the College to add to Mrs. Murphy's $100,000. As a result of their contributions, these individuals were named members of the Murphy Memorial Association. The Murphy daughters' contributed $10,000 each to make up a $30,000 deficit which existed on contracts already fulfilled. To purchase the furnishings for the building, the Board of Regents reluctantly authorized an expenditure from College funds of $75,000, which had to be borrowed from a bank. The building contained a large memorial hall with a stained glass window, pipe organ, rich walnut woodwork and plush seats for an audience of about 625. Carved chairs for the Re- gents, who would be academically robed when they occupied them, formed a colorful backdrop for the dais. A smaller hall on the ground floor was designed to provide a place for a medical museum and clinical research offices. The entire upper story was devoted to the library and literary research department. Massive bronze entrance doors were being made by Tif- fany. These were to display in relief the progress of medicine and surgery throughout the ages.2 The pledge cards which the donors signed carried the statement that the memorial would be maintained in perpetuity by Mrs. J. T. Benedict (Cecile), now Mrs. James E. Baggot; Mrs. Edward N. Hurley, Jr. (Mildred); and Mrs. James G. Murdock (Celeste), later Mrs. Andrew E. Van Esso (deceased). 2 The building was dedicated on June 11, 1926. The Board of Regents accepted the building from The John B. Murphy Memorial Association, as well as a "trust to maintain it in perpetuity as a memorial to John B. Murphy and relieve the Association of all liability and further responsibility." 270 Fellowship of Surgeons the American College of Surgeons in memory of John B. Mur- phy. It is not difficult to understand that Franklin Martin had a sincere desire to perpetuate the memory of his loyal friend. It is harder to understand why strong objections were not raised by the legal counsel of the College, or by those of the Regents who were not wholeheartedly in sympathy with having Mur- phy's name on a building, to binding the College with such a clause. The large memorial hall was never to be used as the site of an annual convocation of the College, for which it was designed, because it was too small. Local medical and surgical societies in Chicago were never to make use of the building to the extent anticipated, so that maintenance of the building became a strain on the financial budget of the College. The influence of men, long dead, prevented even this small identification of these societies with either the name of Murphy or the American College of Surgeons. The memorial building represented in a manner the spirit of the times; it did provide space for the museum, the library and research activities such as the bone sarcoma registry. Each of these and similar endeavors added stature to the American College of Surgeons, which had earned respect and gained dignity. As Walter Chipman, the President from Montreal, said at the twelfth convocation in 1924, "The American College of Sur- geons is at the gateway of youth, its childhood is behind it." There was a feeling of expansiveness and success which fitted the general social and economic atmosphere.

Surgery, Gynecology dr Obstetrics was nearing its twentieth anniversary and its circulation was steadily increasing. From earnings of the journal, Franklin Martin in 1922 purchased the property at 660 Rush Street immediately east of that upon which the Murphy memorial building was erected. This house and its combined stable and servants' quarters were situated on one of the four corner lots of Rush and Erie Streets, all owned by members of the McCormick family. The stable and servants' building was remodeled to provide a home for Surgery, Gyne- Fellowship of Surgeons 271 cology di- Obstetrics. The college and The Surgical Publish- ing Company now owned the entire north side of Erie Street between Rush and Cass Streets. Martin then bought back the few shares of stock in the publishing company which were still in the possession of his younger colleagues who had met in his home to plan the beginning of the surgical journal. With the exception of Allen Kanavel, each received twice the amount of his original investment. Recognizing that the success of the scientific and literary character of the publication was due entirely to Kanavers judgment, administrative ability and scholarly attainments, Martin gave him $10,000 in return for his original investment of $2,500. Following these steps, Martin announced to the Board of Regents on October 25, 1923, that upon his death the ownership of The Surgical Publishing Company would pass to Mrs. Martin for the duration of her life. Following her death, stock of the company and all of its properties would be willed to the Ameri- can College of Surgeons. This property, free of all encumbrances and subject to possession by Franklin and Isabelle Martin during their lifetime, was formally accepted by the Board of Regents in 1930. William J. Mayo and Franklin Martin continued to be effusive in their enthusiasm for the South American countries and the influence which the College could exert upon surgery throughout Latin America. Dr. Edward I. Salisbury was placed on the staff of the College in 1924 and was given the specific duty to travel in those countries and spread the philosophy and aims of the College among the surgeons. He was to assess their surgical abilities, the quality of medical education and opportunities for training in surgery. The enthusiasm of Mayo and Martin, two imaginative, quick- witted and voluble men, was contagious. The Finance Com- mittee of the Board of Regents bought a proportionately large number of bonds of several South American countries.

Harper's Magazine contained an article in its February 1924 issue, written by William G. Shepherd, a free-lance writer, entitled "The New Control of Surgeons." The article high- 272 Fellowship of Surgeons lighted the events which had occurred during the 10 years following the first convocation of the College, with emphasis upon the voluntary action of the surgical profession to elevate its standards of education, training and practice. All of the activities of the College, slow in their beginnings and agoniz- ingly discussed by the Regents, began to bloom simultaneously. By 1925 the endowment of the College had reached $622,000, an amount which rightfully produced a glow of success among the Regents. There were 7,400 Fellows. John E. Jennings of Brooklyn proposed that the Regents authorize the formation of a local chapter of the College so that the Fellows in his community could have scientific and social meetings to exchange their views for the good of the organization. Eight surveys of hospitals containing 100 beds or over had been completed; hospitals of 50 to 100 beds had been evaluated four times and those hospitals of less than 50 beds had been inspected twice. This had been a tremendous undertaking, but at last the movement had gained recognition and co-operation. Of the 995 hospitals of 100 beds and over in the United States and Canada which had been surveyed, 826 were fully approved in 1925 as meeting the standards established by the American College of Surgeons. Fifty-six per cent of the hospitals of 50 to 100 beds and 18 per cent of those of 50 beds or less were also issued the certificate of approval which had been designed to be displayed in the hospital so that the public might be assured of the standards which it maintained. Some hospitals did not, or could not, maintain the required standards. The Regents adopted the policy of issuing each year an approval list indicating those institutions which were fully or conditionally approved. This action provided the incentive which kept the hospitals from resting on the laurels they had obtained with the original approval. The Board of Regents was faced with the responsibility of providing the money necessary each year to carry on the hospital standardization program, which had been conceived by Ernest Codman and Edward Martin but the extent of which no one had foreseen. They must see to it that the College, Fellowship of Surgeons 273 working alone as it had from the beginning, continued to keep this activity strong and energetic. The bone sarcoma registry had grown until it contained the records of failure, success, x-ray films, pathological slides and follow-up studies of 560 patients. James Ewing and Joseph Bloodgood had worked enthusiastically with Codman. Bert Wol- bach, Frank M. Mallory and other pathologists, associated with the hospitals of the Harvard Medical School and other medical schools over the country, had been generous of their time and knowledge in giving their opinions about microscopic slides of the tissue. Codman had appealed several times to the Board of Regents to write to hospitals and Fellows for their co-operation. Codman was impatient with those surgeons who were fearful of disclos- ing bad management of the patients. Good or bad, he argued, the case must be recorded so that standard terms could be adopted and the absurdities evident in the descriptions by pathologists and surgeons could be abolished. Financial support to the limit of their resources was supplied by the Regents, and a book, compiled from the records and written by Codman, was serially published in issues of the Bulletin and sent to each Fellow. Bowman C. Crowell, a pathologist formerly of the Oswaldo Cruz Institute of Rio de Janeiro and Professor of Pathology at the Jefferson Medical College, was engaged as the Director of Clinical Research on October 27, 1925. The work of the bone sarcoma registry had outgrown Codman's facilities and capacities, and he was pleased that the Regents had finally found it possible to finance the program in clinical investigation which had been one of the principal functions described by Franklin Martin in his concept of the American College of Surgeons. The registry, with all of its records and specimens, was transferred to the College headquarters. Following Codman's request, Dal- las B. Phemister, a Chicago Fellow of the College, was appointed to supervise its work. The work of Robert B. Greenough's committee to study the treatment of cancer with radium and roentgen rays, fell natur- 274 Fellowship of Surgeons ally within the new department directed by Crowell. The records of 1,204 patients with cancer of the cervix of the uterus, collected from 20 hospitals in seven cities, had already been reviewed and studied. Here again the work of the committee had to be directed in the beginning to the collection of fundamental facts. It was necessary to secure uniform methods of recording, classifying and reporting on cancer in all locations of the body so that the collective experience from a vast amount of material could be utilized. The committee quickly found that reports on cancer of the cervix from various clinics, prepared under different conditions and analyzed with different criteria, could not possibly be compared. As the study progressed, the committee's report to the Regents optimistically recommended that the work be extended to cancer of the breast, mouth, tongue and jaws. From the beginning, there was close co-operation between the American College of Surgeons and the American Society for the Control of Cancer. Many Fellows of the College were members of committees of both organizations. Newspaper articles about the recognition and curability of cancer, placards displayed in public places and special meetings of medical societies devoted to the subject of the prevention and treatment of cancer were the result of joint efforts. A series of 16 articles on cancer had appeared in 1,507 newspapers in 43 states. The American Society for the Control of Cancer had distributed 700,000 copies of "What Every Woman Should Know About Cancer." An article on "Danger Signals of Cancer" was published in 22 languages. The first international symposium on cancer was held under the auspices of the American Society for the Control of Cancer at Lake Mohawk, New York, in September 1926. The proceedings of the meeting were published in a separate number of Surgery, Gynecology & Obstetrics. The utilization of the cautery in the removal of malignant lesions had been practiced for some time, and with the devel- Fellowship of Surgeons 275 opment of the radio came Bovie's use of a high frequency current which could be used for coagulation or cutting in surgery. Howard Kelly, Martin Tinker, Ernest Sachs, Edward Keyes and other surgeons wrote about its use in their special fields of surgery. Franklin Martin's early interest in the use of electricity in surgery was rekindled, and through his efforts the Grigsby- Grunow Company, manufacturers of the Majestic radio, built and distributed to hospitals and surgeons in the United States and Canada, without cost, 200 electrosurgical units. The Col- lege committee investigated the extravagantly publicized favorable claims of the Coffey-Humber treatment of cancer which employed an extract of the adrenal cortex. 8 Regularly, the Board of Regents critically reviewed and discussed the efforts of the College in the cancer fight. They wished to undertake the promotion of better service to patients suffering from cancer. Could it be best accomplished by helping to establish institutes for the study of cancer, by financing research laboratories, by building hospitals for the treatment of cancer patients exclusively or by encouraging the foundation of clinics in general hospitals, realizing that the family doctor must be taught to recognize cancer early in its existence so that treatment could be instituted without delay? The Board of Regents finally established its lines of endeavor. The College, through its clinical research department, would

3 Drs. Walter B. Coffey and John D. Humber began to treat cancer patients with an extract of the adrenal cortex and established clinics for this purpose in San Francisco and Los Angeles. The Board of Regents appointed a committee of Charles H. Mayo, George W. Crile, F. A. Besley, Major G. Seelig, Frank W. Lynch, James P. Simonds and Bowman C. Crowell to investigate the methods and results of the treatment which had attracted thousands of patients. After a careful firsthand study from April 4-18, 1930, the committee reported that they had examined the records of a large group of patients who had received exactly the same treatment; that the doctors insisted that it was a clinical experiment; that changes in the gross and microscopic appearance of tumors had been demonstrated; that the credibility of patients' statements militate against their accuracy, and that they could not make a definitive statement about the value of the therapy. 276 Fellowship of Surgeons aid in the education of the public to seek an early diagnosis and treatment. It would help advise the medical profession to utilize the best method of preventing and treating cancer; it would investigate all alleged cures which appeared to have even the slightest scientific basis, and it would continue to analyze and study the records of patients treated for cancer. The committee of the American Society for the Control of Cancer reported simultaneously on the medical service available in the United States for the treatment of cancer patients and suggested a widespread organization of cancer clinics in general hospitals. So that a stamp of approval could be provided for the laity, the directors of the society requested the College to formulate a minimum standard for these clinics, to encourage their establishment and to survey the existing facilities and those to be formed.

Charles L. Scudder of Boston and John B. Walker of New York were actively working with the committee on the standardization of the treatment of fractures. In 1924, a total of 151,000 fractures of bones had been treated in 1,050 hospitals in the United States. The results of treatment concerned the committee. The committee stated that medical students did not receive proper and adequate instruction in the treatment of fractures. They believed that one surgeon should be placed in charge of the care of fractures in each hospital which should contain at least the minimum of equipment for treatment. This requirement could be correlated with the minimum standards program for hospitals. Many meetings were held with hospital staffs, and members of the committee spread their gospel by papers read at medical society gatherings. What should be done immediately for the injured person who might have a fractured extremity? What splint material should be carried by ambulances? What kind of improvised splints could be used and how should the patient with a fracture be transported? Immediately, the committee planned for the publication of a manual which would contain the consensus of the accepted Fellowship of Surgeons 277 immediate and later treatment of fractures. 4 This project, too, required money and Franklin Martin began to think of his past relations with Samuel Gompers and William Green of the Amer- ican Federation of Labor and possible support also from industries and insurance companies. The surgeons for the railroads had already exhibited their interest in the work of the committee on fractures. The Board on Industrial Medicine and Traumatic Surgery 5 might well include the work of the committee on fractures at the same time that it extended its aims to improve the health and care of the individual injured at his work. The medical services of industry should be surveyed and a minimum standard for plant dispensaries and other medical facilities formulated. It was proposed to the Regents that a class of Fellowship be established in the College which would permit the acceptance of a limited small number of doctors who directed the medical affairs of large industrial concerns and who might be called administrative surgeons. The Committee on Standards for Laboratories in Hospitals had found that only 38 per cent of 5,335 hospitals with 100 beds or less had a clinical laboratory. In less than 100 of the remainder, the attending doctors performed the simple tests of examination of the urine for albumin, blood and sugar. In the other hospitals laboratory tests were not done. The committee recommended that in hospitals with an annual financial budget of between $25,000 and $40,000, a total of $1,000 should be spent upon a laboratory service. Perhaps, in such hospitals not too far removed from each other the laboratory service could be a joint enterprise. Five per cent of a total operating budget of between $50,000 and $150,000 should be

4 Principles and Outline of Fracture Treatment. Bull. Am. Coll. Surg., 15:3, 1931. In 1932, this article was reprinted as "The Outline of the Treatment of Fractures" and was republished under this title in 1932, 1933 and 1940. The name of the committee concerned with the health problems in industry and the treatment of injuries received at work was changed several times. The Committee on Industrial Surgery became the Committee on Traumatic Surgery. The name was later changed to the Board on Industrial Medicine and Traumatic Surgery, probably with the thought of attracting more interest from industrial firms. 278 Fellowship of Surgeons the minimum amount invested in a laboratory. In a hospital of 300 beds, a director, bacteriologists, pathologists and technicians should be employed to provide proper service to the patients and the staff. The committee, which consisted of pathologists and bacteriologists, was pessimistic about the chances for accomplishing these recommendations. It was not difficult, however, for the Regents to decide to include them in the minimum standards required for approval of the larger hospitals. Thus, the goal was soon attained. The same formula of procedure was suggested to the Regents by James T. Case for elevating the standards of radiological equipment in hospitals. Again, the Regents went outside the Fellowship to enlist the services of radiologists, Henry K. Pan- coast and Preston M. Hickey, to serve with Case on the committee. The advent of sound in the making of motion pictures immediately renewed the interest in using this medium in the teaching of medical students and in medical society meetings. It had also become possible to animate illustrations by photographing hundreds of separate drawings. Will Hays, the former Postmas- ter General of the United States, had become the czar of the motion picture industry in a move analogous to that employed by the American and National baseball leagues when they engaged the services of Judge Kenesaw Mountain Landis. Hays became interested in the public relations value of educational films in the field of medicine. To inaugurate the program, he arranged to have the Fox Movietone Company make a motion picture of the Regents and officers of the College at the 1929 Clinical Congress in Chicago. Just previously, the Eastman Kodak Company financed the making of a teaching film on infections of the hand. This film was supervised by Allen Kanavel and was ready for distribution for the use of the Fellows of the College in January 1928. The American Board of Otolaryngology followed the precedent set by the ophthalmologists and requested that the certificate of its board be accepted as evidence of qualification for Fellowship of Surgeons 279 Fellowship. This was granted by the Regents, but the requirement of submitting the records on 25 patients was added. Soon after, the surgeons who practiced in the specialty of urology, for which group a board of examination had not been established, asked for consideration to be admitted to the Col- lege as Fellows. The practices of the majority of the doctors interested in diseases of the genitourinary tract were dominated by the office treatment of venereal diseases. Some with a modi- cum of surgical training were operating for the removal of kidney tumors and prostatic enlargements. With the guidance of J. Bentley Squier, a surgeon who devoted his interest to urological surgery, the Board of Regents stipulated that such applicants show evidence of familiarity with certain diagnostic and therapeutic procedures in this specialty of surgery and submit records of the operations which they had performed. These were to include a formidable list of surgical procedures specified by the Board of Regents. To encourage the keeping of good records, Surgery, Gyne- cology & Obstetrics offered a cash prize of $500 to the initiate who submitted the best records in support of his candidacy to become a Fellow. The prize money was to be used to obtain a life membership in the College. So that the business affairs of the College could be brought before the Regents more efficiently and promptly, a Finance Committee was established. One of the first actions of the committee resulted in a request to each new Fellow for a contribution to the Endowment Fund of the College. This appointment of a committee on finance followed the death of Albert J. Ochsner 6, who had served loyally and faithfully as Treasurer, Regent and President of the College. Ochs- ner had been the "watchdog" of the treasury. Although criticisms of the methods of handling the funds of the College had been directed at Martin, Ochsner had resented their implications upon his personal honesty and had been outraged at their inconsistency and promiscuity. ° July 25, 1925. 280 Fellowship of Surgeons A resolution passed by the Board of Regents approved the formation of a foundation for clinical research within the College which was to honor Ochsner's name. Contributions were to be obtained from his multitude of patients and the many physicians who referred their patients to him for surgery. Franklin Martin outlined the proposal convincingly, but the response was discouraging and the plans never materialized. The need for money was paramount in the minds of all the Regents. The College had spent $2,000,000 to carry on the work entailed in the programs which had been instituted so successfully. There was $2,370,000 in assets represented by property and the Endowment Fund. Martin was constantly on the alert to find sources of bequests and gifts to the College. In conversations with laymen he invariably described the work of the College with a personal application to the listener. Dr. Agnes C. Vietor, a Fellow of the College from Boston, proposed to leave $50,000, the income from which upon her death would benefit two friends during their lifetime. After their death, the American College of Sur- geons would hold the principal in trust for the American Col- lege of Physicians, if and when it was organized, and in the interim would use the income for research. Even this complicated futurity was considered hopefully for a short time by the Regents. It seemed necessary to have one of the Regents serve as Chairman of the group continuously instead of following the old plan of electing a Regent to preside at each meeting, or giving that honor to the President. Such a Chairman could maintain a sustained interest and could materially help Martin in fund raising. George W. Crile was elected Chairman of the Board of Regents on June 11, 1926, with the tacit understanding that he would be formally re-elected each year. Martin needed the help of a man like Crile who could exhibit sustained enthusiasm for their goals. Franklin Martin had become acquainted with William C. Grunow, a young businessman in Chicago whose company manufactured the Majestic radio. Grunow was an enthusiastic, Fellowship of Surgeons 281 free-talking man who at the age of 16 had been left the responsibility of caring for his mother and two brothers when his father, a cigar maker, had died. Entering the army as a private in World War I, he had been discharged with the rank of captain and had served as a general's aide. His advertising and promotion sales campaigns for the radio with the first dynamic speaker, manufactured on an assembly line and sold at a popular price, had catapulted the Grigsby-Grunow Company's business to unprecedented heights. The stock of the company was being bought and sold on all of the large exchanges in the country. Grunow had become a rich man with the speed and quick action typical of the roaring twenties. He was anxious for recognition of his abilities as a business phenomenon and, by his building of homes and display of possessions, called attention to his indisputable talents for promotion. Martin and Grunow shared an interest in Arizona and the Southwest, which led Martin to recommend the climate for the relief of the pains of an old wound in the foot which Grunow had suffered during the War. This was quickly followed by Grunow building a home in Phoenix, Arizona, and his establishing a clinic in a newly constructed building so that a group of doctors could practice medicine in a manner similar to the methods of the Mayo Clinic. Martin's interest and help in this form of a memorial to Grunow's daughter, who had died as the result of an operation under a mistaken diagnosis, provided the opportunity to convince Grunow that he should help the Ameri- can College of Surgeons carry on its program in clinical research. Grunow proposed that he give $2,000,000 as an endowed fund to the College. He presented the College with a check for $50,000 to represent the interest at five per cent on the principal stun for two quarters. It seemed that worries over financing the clinical research program were at an end, though the principal sum was not in possession of the College. The air of euphoria produced by this windfall was increased by the announcement to the Regents that Grunow wished to give an additional $3,000,000 to be used for the erection of a building 282 Fellowship of Surgeons for the College. An architect drew the exterior elevation of a multi-storied building which was to be placed in a parklike area with entrance and exit gates in the block which Franklin Martin was convinced should be completely owned by the American College of Surgeons as soon as possible. The entire north side of Erie Street from Cass to Rush Streets was already in the possession of the College and The Surgical Publishing Company. Martin had his eye on a piece of property at 650 Rush Street, owned by another member of the McCor- mick family. Located on the southwest corner of Rush and Erie Streets, this would be the beginning of the acquisition of the property on the south side of Erie Street. Martin was convincing in his presentation to the Board of Regents, outlining as he did the growth of the city northward, the increasing value of property in the area and the creation of an island of a beautiful building surrounded by trees and lawn in the midst of bustling business activity. Everyone was prosperous. Land values were high, it was true, but they were going higher and delay would be expensive. Some income could be received from rental of the house which stood on the property, or one of the expanding departments of the College could utilize the space. Franklin Martin never made a presentation to the Board of Regents without attempting to anticipate their searching questions and being prepared with an answer. They would be able to meet the price of the property, $425,000, by negotiating a loan of $200,000 from the Continental National Bank and Trust Company. Martin then proposed that the Regents authorize the removal of not more than $300,000 in securities from the Endowment Fund held in The Northern Trust Company to be used as collateral. Certainly, as Walter Chipman said, the American College of Surgeons had left its childhood behind. In turn, its organization had been used as a pattern in another vigorous, young country. In August 1926, the Royal College of Surgeons of Australasia was constituted along similar lines and with comparable objectives. A salutation was sent to the new College in Australia Fellowship of Surgeons 283 from Boston, where the majority of the profession was openly antagonistic to the College of Surgeons, although three of its most prominent surgeons had originated and were chairmen of the three most vigorous clinical research programs. It had become the custom for the Board of Regents to name the nominating committee for the election of officers and Re- gents. In 1927, Franklin Martin was elected President of the College against his remonstrances. His friend, Charles Mayo, congratulated him and said that he had "talked with all the men so there would be no room for argument on your side. Everybody felt that you must be president and there was no use waiting for a future date and Will and I felt that there was no need to discuss anyone else for the presidency except you." William Mayo wrote Martin: . . . that behind the movement which I was so glad to sponsor was a feeling that life is fleeting, and that one who has done such great work should be distinguished by the highest honor in the gift of the association. I cannot see that the presidency in any way will interfere with your future relations with the Board, and I would suggest that at the end of a year you consider taking the title of Chairman of the Board of Re- gents and Director of the College Activities. This would permit you to do the same work but would add dignity to your position. It is practically my own relation to the Mayo Clinic; it is what Gary was to the Steel Company, and what Marvin Hughitt was to the North Western Road. I am not at all certain that your salary is as much as it should be, and with your permission I should like to take steps to raise it to an amount more fitting the great responsibility you carry. In his presidential address, Martin emphasized that the Col- lege had sponsored community meetings to discuss health problems. He also presented a plan for health inventoriums in hospitals which he said would result in thorough periodic health examinations and insure the independence of the family doctor, the favorite internist and surgeon. It would also save the public from the exploitation of unworthy groups, stock companies and 284 Fellowship of Surgeons even the well-organized clinics or well-equipped dispensaries or hospitals. He ventured to predict that accurate statistics would record an extension of longevity from an average of 58 years in 1920 to 65 years in 1930 and a postponement of senility. In his address of welcome at the 1928 Clinical Congress held in Boston, Frederic Cotton said, "In Boston, I think we hardly realize what has been accomplished, for this is an old well developed medical centre, and even fifteen years ago was pretty ripe and reasonably free from most vices and defects save those of old age, and too much tradition. The country as a whole was younger, more rampant, not organized at all so far as our special profession was concerned, working in little units under conditions of hospital and private practice that could hardly be called favorable, inarticulate and in large measure without definite standards, without definite direction of effort." Though the air of expansion and euphoria permeated the land and touched the American College of Surgeons, the Re- gents continued to give their time and patient consideration to the more mundane problems which confronted them among the Fellows. Some applicants presented the records of patients' histories which could not be verified. Fellows were expelled for "advertisements" which they placed in newspapers; some failed to pay their dues and were dropped summarily. Fee-splitting continued to occupy the minds of the Regents and when evidence was presented which was more than hear- say, expulsion of the Fellow was recorded. Hospitals were taken from the approved list when evidence against individual fee- splitters was not obtainable but when suspicions were well founded that the practice prevailed among the attending staff. All of these actions of the Board of Regents were recorded in the minutes but went unpublicized. Subsequent directories of the Fellowship simply omitted the names. The twenties were notorious for happenings other than the bullish complexion of the stock market and business. On Octo- ber 18, 1921, the United States Senate ratified a joint resolution

7 Cotton, F. J.: Address of Welcome. Am. Co//. Surg. Yearbook, 16:112, 1929. Fellowship of Surgeons 285 of Congress declaring peace with Germany and Austria. Two years later, the first sound-on-film talking pictures were shown by Lee de Forest at the Rivoli Theatre in New York City, and on November 12, 1923, Adolf Hitler was arrested and impris- oned at Landsberg where he wrote Mein Kampf. Charles Lindbergh made his non-stop airplane flight from New York to Paris in 1927. The year 1929 carried bad news from its beginning. The St. Valentine's Day massacre occurred as the result of a prohibition gangland war in Chicago. A fire in Crile's Cleveland Clinic Hospital combined with the nitrogen dioxide fumes from burning x-ray films to cause the deaths of 124 patients, doctors and employees. Albert B. Fall, former Secretary of the Interior, was convicted of accepting a bribe of $100,000 from Edward L. Doheny in the leasing of the Elk Hills naval oil reserve during President Harding's administration. On October 24, 1929, the New York Times headlines read:

PRICES OF STOCKS CRASH IN HEAVY LIQUIDATION TOTAL DROP OF BILLIONS Some optimists called the break in the market a "technical" one, but on October 29, American Telephone and Telegraph stock lost 34 points and General Electric Company's stock dropped 471/2 points. There was a nation-wide stampede to un- load stock, and on October 30, 1929, the market collapsed in a 16,410,030 share trading day. The depression seriously affected the College. The value of the South American country bonds decreased, and interest payments of other bonds failed. The staff of employees had to be reduced materially, and those who could be retained agreed to a 10 per cent salary reduction, as did Franklin Martin. Upon request of a considerable number of the Fellows, the Regents approved a postponement of the payment of their dues. With the business crash went Martin's hopes for a two million dollar gift for a building from the ebullient William C. Grunow.

There were murmurings of renewed criticism of the College; this time directed at all of the Regents and past Presidents. 286 Fellowship of Surgeons William J. Mayo felt it his duty to come to their defense. "As is true in great universities," he said, "we seek stability by retaining faithful trustees as long as their services are available and they accept the responsibility of regular service." Mayo emphasized the personal sacrifices of time and money which those who served on the Board of Regents and as officers had made to help elevate the standards of surgical care of the patient. Their decisions were never based on expediency nor were their responsibilities marred by politics. They intended to continue to work toward improving the training of the young doctor to become a surgeon. To this end, the Regents accepted the invitation of Dr. Fred C. Zapffe of the staff of the American Medical Association to appoint a committee to study the undergraduate, graduate and postgraduate teaching of surgery and the surgical specialties in medical schools. Franklin Martin reminded his colleagues that he had insisted from the beginning that the universities and their medical schools should assume the sole responsibility for placing the stamp of approval upon surgical education and training. He heartily supported the appointment of a committee by the Regents on December 8, 1930, consisting of Fred C. Zapffe, chairman; Elliott C. Cutler, Professor of Surgery, Western Re- serve University School of Medicine, Cleveland; Irving S. Cut- ter, Dean of Northwestern University Medical School, Chicago; George J. Heuer, Professor of Surgery, University of Cincinnati College of Medicine, Cincinnati; Alexander R. Munroe, Pro- fessor of Surgery, University of Alberta Faculty of Medicine, Edmonton, Alberta, and Allen 0. Whipple, Professor of Sur- gery, Columbia University College of Physicians and Surgeons, New York City. This was the beginning of a more formal interest on the part of the College of Surgeons in the field of the early training of the surgeon. However, when the first report of the committee was presented to the Board of Regents, Evarts A. Graham of St. Louis, who had been elected First Vice-President of the Col- lege, said that he "looked with great apprehension on the Col- Fellowship of Surgeons 287 lege entering into any proposal of any sort which might have as its result the standardization of medical education beyond what might be considered minimum requirements." Graham had become the Professor of Surgery at Washington University Medical School. He had received his medical education at Rush Medical College and his surgical training at Pres- byterian Hospital in Chicago under the tutelage of Arthur Dean Bevan. He served as chairman of the local committee on arrangements for the 1932 Clinical Congress held in St. Louis. In accordance with a custom, which was not entirely invaria- ble, Graham was elected First Vice-President of the College at the annual meeting of the Fellows in St. Louis on October 20. Graham objected strenuously to having been elected to the vice-presidency without first having been consulted and his recriminations reached the ears of the members of the Board of Regents before the Congress adjourned. The Regents had already had experience with Harvey Cushing under similar circumstances. Franklin Martin sought out Graham, talked with him and then wrote him from Chicago on October 24, saying in part, "Nothing pleased me so much as the fine talk we had together on Saturday morning." Martin said that it had made him realize how little the rank and file of the Fellows knew about the real inner workings of the College. He pointed out the changes made in the personnel of the Board of Regents year by year. He said that Vice-Presidents were ex-officio members of the Board of Regents and he hoped Graham would find it possible to attend each session of the Board and also the meetings of the Executive Committee. He ended a long three-page, single-spaced typewritten letter by saying, "And I hope now that we have won your interest that you will become one of the future supporters and delibera- tors in our effort to make the College what it should be. At- tendance at one or two meetings of the Board will convince you that it is a deliberative body that is working with every ounce of its influence to make the College what the best surgeons in the country would have it. Your two years of service, 288 Fellowship of Surgeons of which I hope you will take advantage, will make you, I am sure, one of the staunch supporters of our organization." Frank- lin Martin was never able to know how true his prediction would become. Graham wasted no time in exhibiting an active interest in the College. The next regular meeting of the Board of Regents was to be held in Chicago on October 10, 1933. On July 14, 1933, Graham sent the following letter to 20 surgeons, whom he considered to be leaders in American surgery: 8 I am writing to you to ask you to give me some suggestions about the American College of Surgeons. Entirely without my knowledge or consent, I was made a vice-president of the organization last year and I have been invited to attend the meeting of the Board of Regents next fall to express my views concerning the College. I have certain rather serious criticisms to make of the College and of the way in which it has been administered. At the same time, I feel that there is much to commend about what it has done and is trying to accomplish. I hope to present a program which will put it somewhat more in touch with the men of our own generation who have now come into the positions of leadership in surgery in the country in much the same manner as those who founded the College were at the time of its organization. I feel that we have been neglected, that our opinions have neither been asked for nor received in a proper spirit when given, and that as a result the College has lost the enthusiastic support of the men who at the present time occupy the most influential positions in American surgery and who ought to be enthusiastically behind it. I am writing to about twenty of the men of our generation whom I consider to occupy the most influential positions in surgery in the country. It would help me very much in preparing a program to present to the Board of Regents if you would

8 Barney Brooks, Edward D. Churchill, Frederick A. Culler, Elliott C. Cutler, Samuel C. Harvey, Carl A. Hedblom, George J. Heuer, Emile Holman, E. Stan Judd, Frank H. Lahey, Edwin P. Lehman, Dean D. Lewis, John J. Morton, George P. Muller, Howard C. Naffziger, Alton Ochsner, Dallas B. Phemister, Mont R. Reid, Erwin R. Schmidt and Allen 0. Whipple were recipients of Evarts Graham's letter. All were professors of surgery and many were chairmen of the department of surgery in their respective medical schools. George P. Muller had been elected to the Board of Regents in 1930. Fellowship of Surgeons 289 express yourself candidly in regard to criticisms of the policies of the College and also regarding any constructive ideas which you may have. If you desire not to be quoted, will you please say so in your answer. In private personal conversations which I have had from time to time with those in authority I have been rebuffed. I wish to show, as I believe to be the case, that the ideas which I have suggested from time to time really represent the ideas of the most influential surgical leaders of our generation. I do not know of any other way in which to convince those in charge of the College unless I can state that after canvassing twenty of the influential leaders I have found that certain criticisms stand out. On September 12, 1933, Graham acknowledged the formal notice and invitation to the meeting of the Board of Regents, saying, "I am not quite certain from your recent letter, or from letters which I received from you last fall, whether I am to be given an opportunity to say something at the meeting. I would greatly appreciate information on this point." In reply, Martin quoted from the bylaws of the College and said that it had been the custom to invite Vice-Presidents to attend the Regents' meetings. He also wrote, "At these meetings, they discuss the problems of the College as freely as the elected members of the Board, and their authority has never been questioned. There have been no contests in the conduct of the Board, which required a test vote, hence the legal phase has never been raised. You will surely be expected to participate freely in the discussions and deliberations of the Board and not merely to sit in as a visitor without voice." Graham was present at the Board of Regents' meeting on Tuesday, October 10, 1933, but did not attend the remaining meetings of the Regents which occurred during the week. He was asked to speak and did so, prefacing his remarks with the statement that after being elected Vice-President, he had received many communications from surgeons of his own age who expressed the hope that now that he was in the inner circle, he would do something to improve certain objectionable features of the College of Surgeons. In preparation, he had written the letter, a copy of which they had before them. 290 Fellowship of Surgeons To summarize the replies he had received, Graham said that there was general approbation of the work the American Col- lege of Surgeons had done in the hospital standardization program, the bone tumor registry, bringing the problem of the early diagnosis and treatment of cancer to the laity, encouraging clinical investigation and research in malignant diseases, educating the profession and the public as to the proper treatment of fractures and other similar projects. However, there was unanimous criticism of the fact that the younger surgical teachers had no intimate connection with the College. They were disassociated; no one cared what they thought. They felt that they could not exert any influence upon the College in any way, and they thought it was run by a clique behind closed doors. In addition, Graham said that he and his contemporaries believed that an annual John B. Murphy oration at the Clinical Congress of Surgeons was a ludicrous idea. Murphy, he said, was not that good a surgeon and should not be held up as an ideal to the young surgeons of the country. The College was guilty of never recognizing the outstanding intellectual achievements made by the living American surgeons. Surgeons were invited from all the ends of the earth to give sometimes excellent, sometimes mediocre and often bad speeches and were then given an Honorary Fellowship. Graham stated categorically that an adequate financial statement in detail had never been presented to the Fellows of the College. Publication of such a statement would do a great deal, he thought, to obviate criticism. He charged that fee-splitting still went on among Fellows of the College and the Regents had done nothing about it. "Fee-splitting keeps surgery in the hands of those unfitted and untrained to do it; it causes unnecessary surgical operations of which tens of thousands are performed each year," said Graham. A more vigorous attempt to combat fee-splitting should be made by the College. The standards for admission to Fellowship, he claimed, were too low and the dues were too high, particularly when there was not a satisfactory accounting. Graham concluded by saying that there was an enthusiastic Fellowship of Surgeons 291 desire among his contemporaries to have the American College of Surgeons continue in an influential manner. It seemed to them to be imperative for the Board of Regents to take cognizance of the opinions among the younger men who represented the best in American surgery. The Regents should, without delay, get these men into the fold enthusiastically. While the College, he said, needed the advice and counsel of older men, the average age of the Regents was 67 years and had the College started out with Regents of that age, it would not have been a success. There should be room on the Board of Regents for the representation of younger men who were acknowledged leaders in surgery. A free discussion followed Graham's remarks. Charles Mayo reminded him that suspicioning the practice of fee-splitting and getting someone to swear legally that it was done were quite different. George Crile, the Chairman, thanked Graham for his criticisms and gently pointed out that audited financial statements were read in detail at each meeting of the Fellows of the College and the books were always open for inspection. He assured Graham that there was not a member of the Regents who would not resign immediately if he believed it would be best for the College. The Regents had been through the same routine of criticism before when they answered the petitions of the Society of Clin- ical Surgery and the Eclat Club. The Chairman of the Board agreed with Martin's suggestion that a detailed reply be written,, mimeographed and sent to each recipient of Graham's letter and to each Regent of the College. This 12-page reply was mailed on December 4, 1933. In the meantime, Martin received a letter from Graham in which he said, "I have felt that I could play a part in emphasizing to many of those who are dissatisfied, the fine &hip which the College has done. I feel that you have accomplished a wonderful thing in the organization of the College and that its present powerful influence on surgery is due almost entirely to your genius and farsightedness. . . . On the other hand,, 1 am frank to say that I do not think that all of the policies have 292 Fellowship of Surgeons been wise and that those in authority ought to know the causes of the lack of enthusiastic interest which exist among many of the men of my generation." Graham enclosed the copy of a letter he had written to each of his 20 contemporaries, summarizing his experiences in the meeting with the Regents. He said that unless there was a spirit of complete frankness on both sides, it would be impossible to smooth out the differences and that only more misunderstanding and more disaffection would result. He hoped that what he considered a modest request to have a committee of the Board of Regents confer with a group of the men of his generation in an attempt to iron out the difficulties would go far to win over those who were presently estranged. Graham interpreted the discussion resulting from his presentation as indicating that there was a belief on the part of "some of those in control of the affairs of the College" that too much emphasis was being placed upon teachers of surgery, especially upon those of the "highbrow" type. This was why, he wrote, he had included Lahey and Judd, who represented large clinics and had no intimate connection with an undergraduate medical school, among the 20 surgeons to whom he had sent his letter. He recorded accurately, in his three-page letter of report to his contemporaries, the detailed discussion between the Regents and him on each point he had raised. He concluded by writing a final paragraph which might appear to contain incon- sistencies: My first experience at a meeting of the Board of Regents convinced me of the enormous potentialities of the organization and of the sincere desire of all those concerned with the formulation of the policies of the College to make it an effective instrument for the good of humanity. I am not optimistic about the results of my own efforts with the Board of Regents. I do not know what action, if any, was later taken by them on my suggestion that a committee be appointed to investigate these criticisms and I have grave fears that perhaps nothing at all will result from my efforts. Unfortunately, I was led to feel that my report was not received in a friendly spirit and Fellowship of Surgeons 293 that I was regarded with hostility because I had ventured to warn them of the existing critical attitude of those whose enthusiastic co-operation would be invaluable to them. The detailed reply to the general criticisms presented by Graham and representing his group was patterned after the reply given to the Eclat Club and the Society of Clinical Sur- gery. Some Regents believed, however, that it did not answer all of the criticisms raised, even though it was replete with facts. The young men wanted to sit on the Board of Regents. Charles Mayo expressed his own views, "I am beginning to think it does not pay for us fellows to hang on in keeping control of things. We must break in younger men while we are here to guide and counsel them. . . . After all we have had a fine time in life and have done more during the last fifty years than most folks have and at a time when we enjoyed it most." Crile became philosophical and wrote Martin, "It is not enough to take account of the other man's opinion. It is necessary also to make him feel that his opinion has been taken into account." In answering the criticism that the College was under the domination of a small group and particularly of one individual, the mimeographed reply quoted the bylaws and the procedures which were followed, indicating the responsibilities and functions of each officer and administrator of the College. The Di- rector General was not permitted, nor had he 'attempted, to substitute his judgment for that of the Board of Regents on matters of policy. The report reiterated the previous statement in this respect. The names and ages, year of election and period of service of every Regent of the College were supplied. The average age at election of the then existing Board of Regents was 50.8 years. Crile, Finney, Martin, Charles Mayo and Robert McKechnie of Vancouver had served 20 years. The terms of service of the other Regents had averaged between three and 13 years. The average age at the time of election of all the Regents who had served the College was 54.5 years. One of the group of surgeons 294 Fellowship of Surgeons to whom Graham had written his letter, Howard C. Naffziger, Professor of Surgery at the University of California in San Fran- cisco, had been elected to the Board of Regents that year at the age of 49 years. The Regents agreed that in the future the Murphy orations should be limited to the presentation of scientific subjects so that they might gain the stature of the Hunterian lectures of the Royal College of Surgeons of England. References to Murphy's life and his surgical accomplishments would be de- leted, although the oration of 1933 did concern only his life in, what was later agreed to be, a manner something less than flattering. The statements of the finances of the College were referred to and the last one was reprinted, but evidently the detailed breakdown of the statements was not satisfactory to the critics. There still lurked the suspicion that Franklin Martin was getting rich from the College and the surgical journal, the stock of which was now completely owned by him and his wife and which he had willed upon their deaths to the College. The alleged laxity of the College in regard to fee-splitting and other irregular practices by its members was more provoca- tive of anger among the Regents than any other criticism. Can- didates about whom there were persistent rumors that they split fees were not admitted to Fellowship, the answer stated. Each candidate's credentials were carefully reviewed by the state or provincial credentials committee, and each committee had been instructed by the Board of Regents that when there was any question as to fee-splitting, or any other unethical practices, action should be postponed until the doubts were resolved. Each candidate was required to sign a specific declaration against fee-splitting before he was admitted to Fel- lowship. Persistent rumors of fee-splitting, or other unethical practices, on the part of Fellows were investigated carefully and, if founded, were referred to the Board of Regents for disciplinary action. The difficulty existed that proof of fee-splitting must be obtained which would be recognized in a court of law. Fellowship of Surgeons 295 The minimum standard for hospital approval prohibited the practice of the division of fees under any guise. When persistent rumors existed that a member of the staff of an approved hospital split the patient's fee, the hospital was notified and, unless the condition was corrected, the name of the hospital was removed from the approved list. The work of each state and provincial judiciary committee was described as were the efforts of the College in securing state legislation against fee-splitting, which was present in 14 states. The statement of the Regents categorically denied that the standards for admission were not sufficiently high, that candidates for admission were not sufficiently examined or their records scrutinized to keep out many who should not be admitted to Fellowship. After careful consideration of all methods, the Regents had concluded that the one employed was the best suited to accomplish the avowed object of the Ameri- can College of Surgeons. Careful scrutiny of the professional, ethical and moral qualifications of every candidate by four different committees seemed to them to be a sufficient safeguard of the fitness of the candidate for Fellowship. About 50 per cent of the applications to the credentials committees were approved and the records of about 80 per cent of those approved candidates were then recommended by the committee on history reviews. Finally, the reply indicated the occasions and nature of the appearance on the programs of the College of each surgeon to whom Graham had sent his letter. All had appeared at least once and some at more than one meeting except five, two of whom were not Fellows. This record did not appear to indicate neglect, the Regents said. In his reply of December 21, 1933, Evarts Graham stated more clearly than he had before what he believed to be the primary defect in the organization of the College: I am arguing for a satisfactory representation of the men of my generation in the formation of policies and in some of the control of the College. . . . The point which all along I have tried to make to you is that my generation is not now adequately 296 Fellowship of Surgeons represented on the Board of Regents. . . . If, ten or twenty years ago, it was desirable or necessary to have the Board of Regents a representative group of the most active and influential leaders in surgery of that period, the same holds true today. . . . I will say, however, that I am delighted with the election of Dr. Naffziger to the Board. He does represent the group of active surgical leaders. There are also a few others on the Board who I would say would qualify as members of the present generation of active leaders. Graham called Martin's attention to the fact that in the early days of the College it was evidently considered important to have the heads of the departments of surgery of several of the strong medical schools represented on the Board of Regents. What had happened, asked Graham, to cause the adoption of a different policy? The departments of surgery of the better medical schools of the country, said Graham, were headed by men whose principal job in life was an educational one to develop and train young surgeons. He did not believe that Martin and his colleagues realized that the older method of teaching as an avocation in medicine had given place to the serious business of teaching as a vocation. These men, Graham said, have as their main object one of the things which the College set for itself as its goal, the elevation of training in surgery, yet it appeared that this group was continually ignored. Graham threw aside all pretense of addressing the Board of Regents as a policy making body. His constant references to Martin as the individual who made all decisions were emphasized by his use of the pronoun "you." Graham ended by saying: I cannot help feeling, however, that the structure will be more effective and will endure for a longer time if it has the whole-hearted support of the leaders of surgery of each generation as they come along. . . . I hope also that the Executive Committee will realize that I am not seeking an office of any kind for myself. . . . I hope, however, that my opinions and the opinions of the group for which in a sense I have acted as a Fellowship of Surgeons 297 spokesman, will not always be considered to be of so little value as evidently the executive committee now considers them to be, judging from the statement which has been prepared under their direction. . . . I am particularly disappointed that the only request which I made was completely ignored, namely, that a committee of the Board of Regents should confer with a selected group of the leading surgeons of the present generation in order to iron out some of the difficulties. Graham could not be aware of the difference of opinion which existed within the Board of Regents over this latter point. Martin had recommended that the full Board of Regents and the interested critics should meet in Chicago in the College building where all records would be available. Two full days should be scheduled immediately preceding the sessions of the American Medical Association which were to be held in Cleve- land. "As for me," Martin said, "no one is more interested than I to have any re-adjustments that may be necessary to insure that the great organization of 12,000 surgeons shall not be permitted to fall into the control of unworthy, self-seekers, particularly since all of these surgeons are co-operating and supporting the College with the exception of a disgruntled few." In reply to Charles Mayo's letter, Martin wrote, "I heartily approve of the suggestion contained in your letter about letting in, or more properly drafting, young men to fill the ranks of us old young Fellows when we get tired. That is exactly what we are doing. However, I have no intention of retiring voluntarily under fire." Frank H. Lahey, a surgeon who did not chairman a department of surgery in a medical school but who had organized a successful clinic in Boston, wrote Martin that he definitely agreed with Graham that younger surgeons should hold seats in the Board of Regents. He emphasized that the only, and sincere, desire of his contemporaries was to be helpful to the College of Surgeons and American surgery. Elliott Cutler wrote Martin: "You owe it to yourself, to the 298 Fellowship of Surgeons great structure which you have played such a large part in erecting, and to the future of American surgery, to make a move shortly which will satisfy in some fashion this large group of thoughtful, even if you do not personally consider them valuable, members of the profession of surgery." Franklin Martin was greatly disturbed because he felt that within the body of the Regents there was less than unity in their opinions about the future. Some of the younger men in the past who had been chosen as Regents were not regular in attendance and did not pull their weight in the boat. He became sensitive over the thought that the attacks of criticism should be aimed at him directly but that the praise for the good things the College had done was unashamedly shared by all the Regents. He often gave credit for the origin of ideas and policies of the College to his old and loyal friends, when all they had really done was to be convinced by his enthusiasm and sincerity of the correctness of his views, and then supported him loyally and faithfully. To an unprejudiced observer, there could be no question as to who guided and controlled the policies of the American College of Surgeons. But his friends asked, who conceived the American College of Surgeons? Martin turned to Allen Kanavel, from whom he knew he always received a considered opinion. From California where he had gone on vacation, Kanavel wrote: First, in general, I am delighted with Graham's letter. He has stated the case as fairly as anyone could, who was not familiar with the workings of the College. There is a logical, yet restrained presentation. We cannot hope to escape criticisms and I thoroughly respect one who has the courage to come out frankly, say his say, and send you a copy of what he has said. So, I think we would be lacking in good judgment if we failed to meet him on his own grounds and without malice and without losing our own poise, accept the challenge, and meet with him and the others he may suggest, and with patience and sincerity, try to explain our situation and the facts. . . . We should meet them more than half-way and by our very Fellowship of Surgeons 299 openness, disarm criticism, because after all, we must recognize that the group he represents are important in the future. More- over, they are not all foolish and some are willing to be convinced now and the others will follow later, if we only do not lose our heads and antagonize them. Graham is worth winning since he will probably be the strongest man in surgery ten years from now. Martin had the opportunity of lunching with the scholarly David Cheever in Boston and was pleased with Cheever's un- solicited letter to him: The talk which I had with you at our luncheon meeting in Boston, though approached by me with the fear that my inquiries would seem ungracious, served to clear the air in a most satisfactory way, due to your good-natured and considerate refusal to permit yourself to be annoyed. How true it is that there is scarcely a man who makes himself conspicuous for achievements, whose works, methods, or motives are not criticized and questioned. "Of course," said William Mayo in a letter to Martin, "there has been carping criticism from the very first. A group of men who thought they had this College killed years ago, suddenly found that it had become a great institution and they would like to take over the running of it. I suppose, on the principle that they had run it down as long as they could without success and now, that it is running up instead of down, it cannot get along without them. Personally, I think the treatment they have had for all these years, letting them holler, has been successful and should be continued. What we want is the right kind of men coming along, loyal to the ideals which have been behind the College from its beginning. . . ." This was strong language which did not make Kanavel's advice, to be judicial and constructive with the slow assimilation of a group of younger surgeons, particularly palatable to Franklin Martin. However, the more judicial approach to the problem prevailed. On June 10, 1934, only Samuel Harvey, Evarts Graham, Alton Ochsner, Dallas Phemister and Erwin Schmidt accepted 300 Fellowship of Surgeons the invitation to meet with the Board of Regents. The visitors listened to the time-consuming matters which had to be decided by the Board of Regents, following which there was a free discussion of their criticisms of the College. Allen Kanavel became the spokesman for the Board of Re- gents as one of its more facile speakers who had not yet reached the age of 60. The visitors commented upon the crowding of clinics and the inadvisability of appealing to the public in an educational way and entering non-surgical projects. They thought that the College should direct its attention to establishing and recognizing systems for training men in surgery. Phemister said that he never had any criticism of the College of Surgeons' financial accounting. Harvey suggested establishing "some kind of a council in each state whose membership would be known to the Fellows, these councils to have certain powers, possibly judiciary." As almost everyone knew, judiciary committees were already in existence in every state and province. Kanavel said that one of the important aims of the College was to bring the best possible surgical care to the patient in the smaller community. He stated, "We must encourage the better men in those small communities to do better work. We must encourage the better educated and trained men also, but if we were to exclude from membership all of the men doing surgery in the smaller communities, they would immediately run riot and we would not attain the end toward which the College started—to elevate the entire practice of surgery." Kanavel spoke directly. He said that nine-tenths of the criticism of the College was due to the fact that the critics did not know what the College was really doing, despite the fact that the yearbook, quarterly bulletin and the official journal published detailed reports of the activities of the organization. Evarts Graham repeated his arguments for and insisted upon the addition to the Board of Regents of three or four members from the group of younger surgeons who were chairmen of departments of surgery in medical schools. Samuel Harvey, Professor of Surgery at Yale University, was elected to the Fellowship of Surgeons 301 Board of Regents at the annual meeting in the fall of 1934. The first three of the "young Turks" had obtained seats on the "Supreme Court of Surgery."

Franklin Martin knew that the same problems would recur as history repeated itself. However, perhaps the College could go along peacefully for a period with its really important projects. CHAPTER 9

N THE SPRING of 1930 Franklin and Isabelle Martin returned I to Arizona where it had become their custom to spend the winter months. Martin invariably took his work with him, but this time he had an additional interest. The Democratic national organization was seriously considering Franklin D. Roosevelt for President of the United States. As Governor of New York, Roosevelt was in a strategic position to win the nomination. However, a whispering campaign against him was already under way. Roosevelt's opponents claimed that his paralysis, which resulted from poliomyelitis, would make him physically unfit for the rigorous duties of the President. It was intimated that undoubtedly his brain had also been affected by the disease and his mental capacities impaired. It was characteristic of Martin that he became red-faced and angry in his denials of such "poppycock talk." Here, in his opinion, was a candidate who could bring victory to his party and oust the Republicans who did nothing and whose adminis- trations were riddled with graft and incompetency. During the war Roosevelt had worked with the Advisory Commission, where Martin had observed and judged his capabilities at firsthand. The country needed a younger man who was alert, enthusiastic and full of ideas. Franklin Martin was a vigorous political campaigner. During his vacation, Martin slipped in the bathtub and struck his head. It was not thought to be a serious accident, but he did have a generalized headache which he reluctantly admitted to his wife. He became quieter, she thought, but he would not hear of her suggestion that they return to Chicago and not attend a sectional meeting of the College in Texas. Fellowship of Surgeons 303 At that meeting Martin made his usual speech to acquaint the Fellows with the affairs of the College. He had difficulty finding the right words and complained later that he "had to go around Robin Hood's barn" to get out what he wanted to say.' After examinations and consultations upon his return to Chi- cago, it became clear that as the result of the head injury, he had suffered a cerebral vascular spasm, which produced a slight aphasia and a minimal weakness of his right arm and leg and the right side of his face. After two weeks stay in the hospital, he could be contained no longer since, according to him, "nothing was being done." He returned to his work outwardly just as energetic as ever. Martin was jubilant over the nomination and election of Franklin D. Roosevelt. With his inauguration, events occurred rapidly. Banks were closed on March 6, 1933. The new President inaugurated his radio fireside chats for which his melodious and soothing voice was pre-eminently suited. Adolf Hitler had been made chancellor of Germany, and the United States was aroused by the kidnapping of the Lindbergh baby. The Century of Progress to be held in Chicago was in preparation, and the American College of Surgeons was planning an exhibit there which would visually portray its activities and objectives. A completely satisfactory meeting had been held between the Regents of the College and the directors of the American Society for the Control of Cancer, for whom Clarence C. Little was the spokesman. The Society had decentralized its efforts and had appointed four field representatives in order to correlate the work of various local organizations and institutions engaged in the cancer problem. Orginally, this Society had restricted its activities largely to the education of the lay public, but it had quickly found that the physician also had to be educated. Such a need for parallel education of the layman and physician made the work of the College and the Society correlative. The approval of cancer

1 Personal communication. 304 Fellowship of Surgeons detection clinics, through the organization of the College, was progressing favorably. Within the coming three years, 181 such centers were inspected by the College and met the requirements laid down by the two organizations. The inauguration of Franklin Roosevelt as President of the United States has become a convenient date upon which to place the many economic and social changes which had been gradually taking place in the preceding years. These changing conditions presented new and important problems to the medical profession. Methods of medical practice were altered when groups of doctors united to practice in clinics. Group insurance schemes were instituted to provide benefits for hospitalization costs. Doctors established offices in hospitals. Industrial concerns employed doctors on a part-time contractual basis to care for their employees. Men were engaged as teachers in medical schools on a full-time basis whereby the fees for their services to patients accrued to the hospital or medical school. All of these innovations were disturbing the medical profession. It was charged that under many of the methods which were gaining vogue, it was impossible to render adequate care to the patient, and interference with reasonable competition between physicians of a community had resulted. The government established the Committee on the Cost of Medical Care, with Dr. Ray Lyman Wilbur, Secretary of the Interior and a former president of the American Medical As- sociation, as chairman. Seventeen doctors in private practice, 10 representatives of institutions, special interests in the medical profession and the hospital association, five from public health organizations, six social welfare representatives and nine laymen constituted the committee. The announced purpose was to study the problems of patients, hospitals and doctors and attempt to provide a scientific basis on which the citizens of every community could furnish adequate medical care for all persons at costs within their means. Three years before Roosevelt's election, Franklin Martin had Fellowship of Surgeons 305 organized a symposium at the 1929 Clinical Congress for a discussion of medical and surgical economics by doctors, nurses, hospital administrators and laymen. In 1926, the Judicial Council of the American Medical Association condemned group hospitalization plans which provided medical, surgical and hospital services through the payment of annual membership dues. Hospital costs, physicians' fees and methods of medical practice were all under attack by lay critics. In the November 1930 issue of Harper's Magazine an anonymous author wrote an article entitled "A Patient Looks at Doctors." In it, he expressed the general sentiment throughout the country when he said: What matters is the fact that, in spite of the natural pre- disposition to confidence in the doctor and in spite of the general recognition of the altogether miraculous advances in modem medical skill and knowledge, there is obvious everywhere a growing sense of irritation on the part of the public generally toward present medical practice. Though still somewhat vague and inarticulate, it is already reflected in the increasingly defensive attitude of the profession toward the public, an attitude most marked in the discussions at the last annual session of the American Medical Association. This dis- satisfaction and disillusion on the part of the layman is unfortunately not to be measured by any statistical evidence, but it is obvious wherever two or three are gathered together and the conversation turns to medical experiences. Several independent studies had been under way at the Cornell Clinic, and the Endicott-Johnson company had introduced a plan for medical care in its factory in New York. The Massachusetts General Hospital in Boston maintained a building for the hospitalization of patients of moderate means. This also afforded an opportunity to study the problem. The Bureau of Medical Economics of the American Medical Association issued statements about many plans proposed for hospitalization and sickness insurance. The House of Delegates of the Association was completely unsympathetic to the reports issued by the Committee on the Cost of Medical Care. It was 306 Fellowship of Surgeons a generally accepted view among the medical profession that this committee's report would provide the springboard for the Roosevelt administration to leap into socialized medicine. The American Medical Association's position was stated frequently in its Journal through the Bureau of Medical Economics, the Judicial Council and resolutions passed by the House of Delegates. The tenor of these statements was that all of the group hospitalization schemes in effect, or proposed, violated the principles of professional and ethical conduct in the practices of doctors. The statements also emphasized that any such proposed plan should be studied carefully to determine its ultimate effect upon the future of medical practice and progress of medical science. Plans should not be adopted merely to satisfy a desire for an immediate and, possibly, only a temporary adjustment of financial costs. In the Principles of Medical Ethics of the American Medical Association was a specific section which forbade the solicitation of patients by individual physicians, groups of doctors, by whatever name they might be designated, institutions or organizations. The Judicial Council of the Association wrote into the code of ethics that newspaper and magazine comments concerning the treatment of patients should not be furnished or inspired. However, the American Medical Association did not take the initiative in proposing solutions for the social and economic problems which were engulfing the medical profession. The As- sociation had been assailed as the mouthpiece of ostrich philosophy on the part of a recalcitrant minority of the medical profession. In a conference held in Philadelphia, it had been warned "that the American people were impatient with those who have nothing to offer except the philosophy of keeping things as they are." Franklin Martin knew that the Federal administration was disappointed with the position of the American Medical Asso- ciation which, justifiably or not, it regarded as one of stub- born opposition to any change in the status quo. In fact, Martin was convinced that President Roosevelt was anxious to have the medical profession take the lead and not be forced into action Fellowship of Surgeons 307 by the public or the government. He also knew that the Pres- ident was strongly opposed to dealing further with representatives of the American Medical Association? The Regents of the College unanimously supported the per- tinent clauses of the Principles of Medical Ethics. However, they pointed out that it was highly desirable that fundamental principles be established under which the care of the sick and injured in industry could be improved. It was emphasized in a resolution which the Regents passed that there were patients outside of industry whose financial means were limited and who were subject to group medical and surgical service, contract practice, check off payments, hospital associations, list practice and other economic experiments. The Regents recommended simply that all such patients be privileged to exercise a choice which would provide ethical and competent physicians and surgeons as well as hospitals which met the standards created by the College of Surgeons. The Regents had appointed a committee, known as the Medi- cal Service Board, with Robert B. Greenough as chairman. This committee was established to study modifications of the existing methods of professional practice so that as needs were demonstrated, measures could be evolved gradually to solve them. 8 The committee recognized the existence of five large groups which had difficulties in obtaining adequate medical care. Cited were those indigent patients in communities in which suitable provision for their medical care was not provided through charitable or community resources. Second, there were the ignorant and credulous patients who put their faith in patent medicines, cults and drugstore medications. Third, many individuals lived in frontier districts, either rural or industrial, where it became necessary that a maintenance salary be paid to a doctor to practice in the area. Fourth, there would always Personal communication. ' The Medical Service Board consisted of Robert B. Greenough, Boston, chairman; Bowman C. Crowell, secretary; G. Harvey Agnew, Toronto; Charles A. Dukes, Oakland, California; Franklin H. Martin, Chicago; C. Jeff Miller, New Orleans; Eugene H. Pool, New York; Arthur M. Shipley, Baltimore; J. Bentley Squier, New York; and S. Marx White, Minneapolis. 308 Fellowship of Surgeons exist that group of individuals who were in such a financial position that the costs of serious family illness could only be carried with difficulty within the usual annual income. Finally, there were those who were unable to find in their own community a physician sufficiently equipped to supply them with the benefits of modem medical science. The Medical Service Board gave a great deal of time and thought to the problems posed by changing social and economic conditions. Whereas the name of the committee was not expressive of its aims, the Regents were firmly committed to the principle that it was the duty of the medical profession to assume leadership in all matters which might benefit the doctor's care of his patients. On many occasions previously, the Regents stated that they had an interest in and would co-operate with all other agencies which looked toward providing better medical service to every community. The Regents apparently were of the opinion that the Ameri- can Medical Association was not exerting leadership in vital areas which directly affected patient-doctor relationships. In fact, Martin had been told in no uncertain terms by President Roosevelt in a telephone conversation that this was his opinion.' The Regents adopted the report of their committee unanimously. It offered many constructive suggestions. The community, it said, should assume the direct obligation for the care of the indigent sick and should remunerate all physicians who were engaged in such services. Organizations in medicine were too slow to adopt proper and dignified methods of educating the public to realize that modern medical resources for their protection had progressed rapidly. It was wrong to promulgate old customs and traditions in medical ethics which failed to dispel the ignorance and credulity of the laity. Once again, the Regents emphasized strongly the necessity to improve existing professional qualifications of practicing doctors by extending postgraduate medical instruction. Even more important, they said, it was necessary to improve the qualification and certification of specialists in all branches of medicine. These

4 Personal communication from Franklin H. Martin. Fellowship of Surgeons 309 efforts needed to be promoted so that the public would be fully informed as to the meaning of training and certification of qualifications. These were matters with which the Regents had been dealing since the College was first organized. The difficult problem, however, was how to influence the organizations which were being formed rapidly to provide periodic payment of medical costs incurred by individuals and families of moderate means. Certain general principles should apply, the report of the Medical Service Board stated. All such periodic payment plans should be under the control of the medical profession and its allied services and free from any commercial intermediary organization which operated for profit. One of the most important principles should be the insurance of a free choice of the physician by the patient so that the individual responsibility of the doctor for his patient would be maintained. The payment to the physician should be commensurate with the services rendered, irrespective of the resources available in the periodic payment fund. The medical organization which assumed control of such plans should assume the entire responsibility for the quality of the medical services given. Payment for hospital service and medical care should be quite separate. All plans, it was said rather unrealistically, should be free from features which would encourage professional or financial competition. The Regents accepted the recommendations of its committee that a medical service committee be named in every state and that physicians and surgeons alike constitute the members. 5 These principles were incorporated in the participating insurance plans known as Blue Cross and Blue Shield which were slowly evolved later, only after the demands upon organized medicine became so great that they could no longer be evaded. Immediately upon the publication of the acceptance of the Greenough committee report upon medical service, the House of Delegates of the American Medical Association, meeting in Principles of Prepayment Plans for Medical and Hospital Service. Bull. Am. Coll. Surg., 18:3, 1934. Report accepted by the Regents on October 9, 1933. 310 Fellowship of Surgeons Cleveland on June 12, 1934, adopted a resolution condemning the American College of Surgeons.* The sense of the resolution was an old story. It stated that the American Medical Association was the only democratic body representing the organized medical profession; that medical organizations, or groups representing specialists, did not represent the views of organized medicine and should not purport to guide the medical profession and the public in medical affairs. The resolution also stated that the American Medical Association had repeatedly condemned the issuance of announcements and policies because they embarrassed its attempts to secure adequate care for the health of the American people and, at the same time, protect the ideals of the medical profession. The real issue which triggered the action of the House of Del- egates was the suggestion adopted by the Board of Regents that prepayment insurance plans for medical care be restricted to hospitals approved by the standardization program of the American College of Surgeons. The delegates exposed their personal fears when they added that the restrictions were to extend to the employment only of members of the staffs of such hospitals and to physicians acceptable to such staffs. Quite obviously, they chose to discount the paragraph of the report which specifically dealt with the question of the free choice of a physician and hospital by the patient. Instead, they attacked the last sentence which appeared to offer a threat to their personal security. The offensive paragraph was: (c) The principle of free choice of the physician and hospital by the patient must be assured to the end that the responsibility of the individual physician to the individual patient shall always be maintained. When hospitalization is required, this choice must of necessity be limited to the physicians and surgeons who hold appointments on the staffs of the hospitals participating in the plan or to those physicians and surgeons who are acceptable to the hospital. It is further recommended that only approved hospitals be admitted to participation in such a plan. • See Appendix, Chapter 9:1. Fellowship of Surgeons 311 The House of Delegates instructed the Board of Trustees and the Judicial Council of the American Medical Association to request the members of the Board of Regents of the American College of Surgeons, "who are themselves members of the Amer- ican Medical Association," to explain and justify their attempts to legislate for all the medical profession of the United States which was "truly represented only by the American Medical As- sociation." In present day parlance, the onset of this controversy resembled jurisdictional fights between labor unions. The first objection which came to the attention of the Board of Regents was contained in a letter from several Fellows of the College who resided in Indiana. Their objections echoed those expressed in the resolution adopted by the House of Delegates; the American Medical Association was the only organization which should give authoritative and considered expression of principles governing the practice of medicine as a whole. Naturally, the Regents asked why this had not been done in view of the mounting economic and social changes which were taking place, just as they had asked the American Medical Association years before to take over the standardization of hospital facilities and had met with a refusal. The Fellows from Indiana said that the sole province of the College was to improve the diagnosis and technique of surgery, raise the standards of surgeons and further the science of surgery. The College, they said, could not speak for the large number of general practitioners who would be most seriously affected by any change in the present mode of medical practice. Here, again, the true reasons for the objections were revealed.* The Board of Regents requested Allen Kanavel to draft a reply to the Indiana Fellows. It was to be signed by George Crile, Chairman of the Board. With his usual diplomacy, Kanavel wrote that the Board of Regents always welcomed constructive suggestions from the Fellows and wished to inform them of the reasons for its activities in relation to the many vexing social and economic problems which existed in medicine. He mentioned that the College * See Appendix, Chapter 9:2. 312 Fellowship of Surgeons had received hundreds of letters from Fellows of the College and from hospitals asking for help and advice, which they could not obtain elsewhere, concerning various proposed plans of health insurance. Was a given scheme ethical? Did the College have a plan to propose which would meet the problems arising from the financial depression? Would the standing of a Fellow be jeopar- dized if he participated in a given plan of health insurance? Would the Regents discipline Fellows who had participated in a group plan? Would a hospital lose its approval if it took part in a hospitalization insurance program? The activities of various health insurance and hospitalization plans had been investigated by the College in areas where the problems had been acute for three years, the letter stated. The Regents had then appointed a committee to study the subject in an effort to arrive at a statement of basic principles, according to which replies could be made to such inquiries. The committee made a preliminary report and a year later, the considered report had been adopted unanimously by the Regents. The Regents owed a duty to the 11,000 Fellows and the 2,480 hospitals in the standardization program in Canada and the United States, Kanavel wrote. Certainly, the Regents did not believe they could delegate to any other organization the formation of the principles upon which the guidance of its own Fellows could be based. It was the responsibility of the Ameri- can College of Surgeons to do its part to help solve the pressing social and economic problems which had confronted the medical profession and the laity for such a long period of time. The letter said, not too subtly, that the American Medical Asso- ciation had done nothing and resented any other group in medicine from making suggestions, even for its own membership. Officially, the resolution adopted by the House of Delegates on June 12, 1934, was sent to the Chairman of the Board of Regents with a letter, dated October 12, 1934, from Olin West, secretary of the Board of Trustees of the American Medical Fellowship of Surgeons 313 Association. Quoting from the resolution, and in accordance with its instructions, the letter stated that the Board of Trustees would appreciate a reply from the Board of Regents. Simultaneously, the president of the American Medical As- sociation, Walter Bierring, had written a letter to Crile suggesting a meeting between the Trustees and the Regents. A motion stating that the Regents would be glad to entertain such an invitation at any time was deferred for consideration to the last day of the meeting of the Regents in Boston, October 19, 1934. However, on that day Kanavel and Greenough had prepared a reply of which the Regents approved. The complete report of the Medical Service Board, adopted by the Regents, was enclosed. A careful analysis, the letter said, would indicate the desire of the American College of Surgeons to co-operate with all medical organizations, and other sources of considered opinion, in an effort to seek a solution of the troublesome questions involved in periodic payment plans for hospitalization and medical service. Attention was called to the international character of the College, with Fellows in Canada who were not members of other medical associations in the United States but who were interested in the same problems. The letter was short, direct and non-argumentative, but indicated no withdrawal from the position the Regents had taken. The matter was not to rest with the initial exchange of letters. The Board of Trustees of the American Medical Association instructed West to write the Regents again. In this letter, he quoted from the resolution and the Regents' letter, particularly emphasizing that portion of the resolution which asked the Regents to explain why they, as members of the American Medical Association, attempted to legislate for all the medical profession, "truly represented only by the American Medical Association." At the following meeting of the Board of Regents on April 6, 1935, the Regents replied, in a letter written by Kanavel, that 314 Fellowship of Surgeons they reiterated the desire of the College to co-operate in every way with any movement which would benefit the welfare of the medical profession and improve service to the sick; that the Regents had a responsibility to aid in answering many questions raised by its own Fellows, many of whom were Canadians. In answer to the specific question, which contained an implied threat, as to whether or not the Regents' reply of October 19 was the one which they wished to have submitted to the House of Delegates, the statement was made that "the Board of Re- gents will be very glad to have you use the letter of October 19, 1934, in any way you may choose." At the same time, the Board then answered Bierring's letter, an action which had been postponed previously. The letter stated that President Greenough and Crile, the Chairman of the Board of Regents, would meet with Bierring and one other officer of the American Medical Association in an informal conference concerning the problems which confronted the profession.° The Regents gave specific instructions to their representatives that they were not authorized in any way to accept any suggestions which would impair the independence of the College and its free choice of action concerning the solution of problems which concerned the good of the profession and the improvement of the care of the sick. Newspapers seized upon the controversy raised by the American Medical Association over who had the right to speak publicly for the medical profession. The New York Times headlined the release of the report by Greenough's Medical Service Board to the Regents:

SURGEONS BACK HEALTH INSURANCE - VOTE TO LEAD NATIONAL MOVEMENT - REGENTS ADOPT PROGRAM FOR SYSTEM OF VOLUNTARY PREPAYMENT FOR HOSPITALIZATION AND MEDICAL CARE TO AID PERSONS OF MODERATE MEANS The next day, June 12, 1934, following the statement issued by the American Medical Association, the same newspaper headlined its story: ° See Appendix, Chapter 9:3. Fellowship of Surgeons 315

DOCTORS RESENT HEALTH INSURANCE - RESOLUTION OPPOSING STAND OF SURGEONS OFFERED AS MEDICAL ASSOCIATION MEETS SYSTEMS ABROAD SCORED - BATTLE ON POLICY LOOMS AT CLEVELAND AMERICAN MEDICAL ASSOCIATION REBUKES SURGEONS FOR ADVOCATING SOCIALIZED MEDICINE

This crisis in the affairs of the medical profession had been building up for a number of years. Local medical societies, the American College of Physicians, insurance companies, public health representatives and social welfare groups had held innumerable meetings to discuss the problems involved in medical care. The press became filled with news stories.

NEW YORK DEPARTMENT OF SOCIAL WELFARE APPROVES PLAN TO FORM NONPROFIT ORGANIZATION CORPORATION TO BE CALLED ASSOCIATION OF HOSPITAL SERVICE OF NEW YORK

WAYNE COUNTY MEDICAL SOCIETY PLAN MAKES ADEQUATE CARE POSSIBLE FOR SMALL SALARIED WORKERS

GOLDWATER COMMITTEE WORKS OUT PLAN FOR GROUP HOSPITALIZATION FOR NEW YORK CITY

MAYOR LA GUARDIA URGES DOCTORS TO PAVE WAY

DOCTOR FISHBEIN SAYS THE GOVERNMENT SHOULD ACT ONLY IF DOCTORS FAIL TO MEET THE PUBLIC'S NEEDS

DR. L. I. DUBLIN ON GROUP HOSPITAL PLAN OF UNITED HOSPITAL FUND

ROSS-LOOS GROUP THROUGH INSURANCE AT $2 PER MONTH PROVIDE MEDICAL CARE FOR 150,000 MEMBERS DISMISSED FROM LOS ANGELES COUNTY MEDICAL SOCIETY

GOVERNOR LEHMAN SIGNS BILLS FOR GROUP PAYMENT HOSPITAL CARE - UNITED HOSPITAL FUND So the furor attendant upon the natural development of evolutionary, and sometimes revolutionary, changes in the social 316 Fellowship of Surgeons and economic structure of the United States, as they affected the medical profession, went on. The participants in discussions could never have anticipated that group hospitalization, sickness insurance and surgical fee benefit plans were to become accepted as an integral part of the economic life of the country within a few years. Again, it would appear that the American College of Surgeons had been the force which began a reaction which was to modify the practices of the medical profession. In the following months, Franklin Martin discussed the problems of health insurance and social security with President Roosevelt, who planned to recommend to Congress strong support for the administration's bill known as the Wagner-Dough- ton-Lewis bill to provide a federal social insurance board.° The final result was a bill redrafted by Representative Doughton which established the Social Security Board, without any assignment of duty for the board to study and make recommendations with respect to a federal system of health insurance. Other problems concerned the Regents at the Clinical Con- gress held in Boston in the fall of 1934. There had been some examples of disagreements and deadlocks in the credentials committees of several states and provinces. Qualified surgeons had been kept out of the College for reasons more personal than professional. Since the Regents had the authority to grant Fellowship, they could overrule the action of credentials committees. It had become known also that other regulations concerning the economical aspects of surgical practice, which were not contained in the specific instructions adopted by the Regents and published annually for the guidance - of these committees, had been independently adopted by credentials committees. The Regents, therefore, authorized the appointment of a committee

° At least one of the telephone conversations between the two men was a heated one. It occurred the last week in February 1935, while Franklin Martin was vacationing at the Arizona Biltmore Hotel in Phoenix, Arizona, and preceded the onset of his coronary occlusion by 24 hours. Fellowship of Surgeons 317 of five of their members to consider controversial cases and make its recommendation for adjudication to the Board of Regents. The Executive Committee of the Regents had been studying the revisions necessary to change the bylaws of the College so that the influence of the Governors in the affairs of the Col- lege would be increased. There had been grumblings that the Board of Governors was only an organizational name which on paper supported the appearance of a democracy but in practice meant nothing. The Regents authorized the Executive Commit- tee to draw up such revisions to the bylaws as would be necessary to define clearly the importance of the Governors in the affairs of the organization. To add more fuel to the fire of opposition to the College, Franklin Martin became involved in publicity in Boston resulting from misrepresentation of an interview he granted to a newspaper reporter. Martin's autobiography, The Joy of Living, had just been published. He was persistently urged to grant an interview to John E. Pember, a reporter for the Boston Herald who said he wished to review the book. Mr. James E. King, who was in charge of publicity for the Boston meeting, supported Pember's requests. The interview took place, according to the reporter, in the College headquarters at the Hotel Statler. It was published in the Sunday issue of the Boston Herald on October 21, 1934, two days after the Clinical Congress had ended. The headline read:

IF TAKEN SICK IN BOSTON, WOULD FLY WEST, SAYS SURGEON The article said that Martin triumphantly bragged about the impression the Clinical Congress had made on a "reserved and know-it-all" Boston which had previously affected a supercilious ignorance of the College of Surgeons and its accomplishments. "It will open the eyes of Boston to the fact that the West is on the map in medicine and surgery and not merely a sort of frontier district with all that is worthwhile to be found only on the Atlantic seaboard. There are some fine men in Boston, 318 Fellowship of Surgeons good fellows and all that, but if I were to be taken ill here and were in need of an operation I would go west to have it done. I would fly if necessary, to Cleveland, Chicago or Kansas City, rather than stay in Boston. . . . Where in the world, for instance, is there an institution like the Mayos? . . . The surgeons' surgeons. .. ." Martin had gone to New York, where Frank H. Lahey informed him by telephone about the newspaper article. After getting a copy of the paper, Martin wrote Greenough, Lahey and Arthur W. Allen, who had acted as chairman of the local committee on arrangements, in an attempt to rectify the serious harm which had been done to the relations between the medical profession of New England and the College. Martin stated that Pember had stopped him at the convention hall and introduced himself. Martin said that the reporter had caught him on a busy day when he was on his way to another meeting. He understood that the sketch of his life which Pember was to write would be submitted to him before being published. Martin said that Pember had been complimentary about the public meeting, which had been held in the evening at the Boston Arena, and had also said that he understood that the local committee had been doubtful that such a meeting could be successfully carried out in conservative Boston. Martin said that he replied, "Well, we demonstrated to Boston that it could be done." Martin stated categorically that this was the extent of the interview and that the remainder of the published story was pure fabrication. Several letters passed between Greenough, Lahey, Allen and Martin. Each of Martin's letters revealed his deep distress at the unfortunate impression created by Pember's article. As he wrote to Greenough, "My embarrassments in the past have been based upon criticisms of myself alone, and I have always ignored them. But this time it was different, as it made me appear as an ungrateful slanderer of my best friends. The subtlety of the plan succeeded in stirring me to my depths, and it has all placed me in such a helpless position." Fellowship of Surgeons 319 Allen and Greenough shouldered the heavy responsibility of attempting to mend the broken fences. Both had worked hard to improve the relations between the profession in New England and the American College of Surgeons. They assured Martin that everyone understood how easily reporters misconstrued the meaning of remarks. After a considerable amount of letter writing between George Crile, Chairman of the Board of Regents, and members of the Executive Committee as to the advisability of circulating an explanatory statement to all Fellows of the Col- lege, it was finally decided to allow the incident to fade into the background based on the principle that nothing is as dead as yesterday's newspaper. However, this occurrence, coupled with the argument by Evarts Graham that younger men in surgery should have a responsible part in the affairs of the College, made Franklin Martin partially accept the view that he was getting older and needed the help of energetic young men in the College who would have the same loyalty and enthusiasm for it as he possessed. Immediately upon his return from Boston, he discussed with Allen Kanavel changes in the Board of Regents and suggestions for revisions of the organization of the College. Then, he asked Kanavel to think them over and write him after studying the problem. Martin had obtained approval of the Regents in Boston to call a special meeting of the Regents and the Board of Governors in the middle of 1935 to amend the bylaws of the College along certain lines which he had in mind concerning the administration of the College. Kanavel assured him that the fundamental organization of the College was correct and that it had been demonstrated that fax more constructive work could be accomplished by a small policy-making body than by a more democratic organization such as the American Medical Association with its large un- wieldly House of Delegates. Kanavel agreed with Martin that service on the Board of Regents should be limited, because it would permit education of new men and broaden the influence of the College. Kanavel 320 Fellowship of Surgeons suggested that instead of one term of five years, a three-year term of service should be established with provision for re- election for a succeeding term, thus giving six years of continuous service. An interim of one year would have to elapse before a Regent could again be elected. Stability and flexibility would thus be afforded the Board of Regents, Kanavel thought. He was opposed to the creation of honorary life Regentships which Martin suggested to make vacancies for younger surgeons and yet keep the loyalty and support of men like Crile, Finney and Charles Mayo, all of whom could help perpetuate the ideals of the College by keeping a guiding hand upon the newly elected Regents. Instead, Kanavel proposed the election of honorary Regents from past Presidents and Regents who had given long service to the College. He would limit the number to six who would be elected for a term of five years but would provide for re- election without an interval between terms. The essential difference between their ideas, Kanavel said, was the provision for periodic re-election rather than a life term for honorary Regents. Kanavel said he was fearful of continuous service on the Board of men who were not of the same quality as Crile, Finney and Mayo. Martin found it difficult to think of a Board of Regents without them. Franklin Martin was not excluding himself from the company of men for whom he was attempting to find a graceful way of retiring from the affairs of the College. He had written to William Mayo and in return had received a letter which pointed out the analogy of their positions in the Mayo Clinic and the College. "It does not mean that I have retired," wrote Doctor Will, "but that I am on the Advisory Committee, a position of responsibility in which I can aid in helping those who are to continue to prepare for their duties. . . . I want to be sure that you have a certainty of income to your wife and yourself which you so richly deserve and the place of honor during the remainder of your life, and in the minds of the Fellowship for all time to come." Mayo added that he had not needed Martin's assurance Fellowship of Surgeons 321 that an old scrapper like him would not resign while a whispering gallery went on against his reputation. Franklin Martin's spirits were raised by a letter from his old friend, Edward Martin, expressing resentment against an interview "which I have never known you to give and against statements which I think you are the last man in the world to have made. When you stand still intellectually and dynamically, you will have no enemies. Of course, you have been accused of arson, mayhem, simony and many other derelictions but even your most virulent foe has never thought you a damned fool. Such an interview, if true, would indicate something radically wrong in your little gray cells, which God be praised are working with even more than their superhuman high speed and high power. The reporter has done little harm and since he cannot be kicked, should be forgotten." Martin wrote several memoranda embodying suggestions for his retirement from the administration of the College and its future organization. Early in December 1934, he visited Kanavel in Pasadena, California, on his return from San Fran- cisco where he had gone to make preliminary arrangements for the Clinical Congress to be held there in 1935. Martin had always had confidence in his younger colleague's calm judgment. Together, they worked out a statement which Martin could send to each Regent. Certain premises were defined. The College had succeeded because there was a need to elevate the standards of surgery. While a great deal had been accomplished, there was still need for continuing the work. It was necessary to have an executive officer who was vigorous and who had vision, ability and a deep interest in the ideals and future of the American College of Surgeons. If such a man could not be found immediately, it was necessary to perfect an administrative organization which could carry on the work of the College without interruption. While such an arrangement might not initiate new programs, it could consolidate the advances already made toward the objective of securing the most competent and efficient surgical care for patients. 322 Fellowship of Surgeons The final premise stated that the identity and complete freedom of action by the American College of Surgeons should be maintained. No entangling alliances should be entered into which might jeopardize this freedom of action. Specific suggestions were written down to implement these principles of reorganization. Changes in the personnel of the Board of Regents should be made by evolution, not revolution, so that new young members could learn the problems and develop their interest. The Board of Regents should assume more responsibility for the administration of the College. Since the Board and the administrative staff relied so heavily upon Martin, it was a logical assumption that if he remained as Director General, they would neither initiate action nor assume responsibility. Therefore, it was proposed that Martin retire, with proper compensation, and be named honorary Director General for life. A prophetic statement was made that during the transition stage and until the Board of Regents chose a new Director General, the College should expect an inevitable letdown in progressive work. There should be no undue haste in choosing Martin's successor because the properly qualified man would be difficult to find. Some of the duties, particularly in public relations, which the Director General had carried on should be assumed by the Chairman of the Board of Regents. Suggestions were made for revisions in the bylaws which eliminated the title of Director General and replaced it with executive secretary, provided for a Vice-Chairman of the Board of Regents and specified a one-year term for the Chairman, and created four honorary members of the Board of Regents to be elected by the Board of Governors upon recommendation of the Board of Regents, with all the rights and privileges of regular members of the Board. After discussing these ideas with George Crile, the Mayo brothers and others, Martin crystallized his thoughts. He suggested that those individuals on the administrative staff of the College, who were actually heads of departments, be constituted an administrative committee. He warned that it would not be Fellowship of Surgeons 323 wise to appoint a permanent chairman of this group because it would cause embarrassment when a Director General was finally chosen. Each individual had specialized so exclusively in the matters of his own department that he could not be thoroughly interested in the other areas represented in the College, and it would lead to mistakes because of the assumption of authority. Consequently, it would be better to allow the group to choose a temporary chairman at each of its frequent meetings. Each member of the administrative group should report for his own department directly to the Board of Regents and its Executive Committee. George Crile should be elected Chairman of the Board of Regents and Kanavel should be Vice-Chairman. Crile should then come to Chicago once a month to meet with the administrative group and decide upon policy matters. In a final conference between Crile and Martin on December 21, 1934, in Chicago, it was decided to incorporate these suggestions in a letter to be written each Regent by Martin. His retirement would be set for the time of the Clinical Congress to be held in San Francisco in the fall of 1935. Martin also suggested that Arthur W. Allen of Boston and Alton Ochsner of New Orleans be elected to the Board of Regents and that Vernon C. David of Chicago be appointed to Martin's place on the Board. On December 29, 1934, Martin wrote a formal letter to Crile, with a copy to each Regent, stating his intention to resign as Director General and asking that Crile appoint a committee to consider the situation which would thus be created. Martin sent an accompanying letter to each Regent calling attention to the resolution, which he had introduced to the Board of Regents, recommending a joint meeting of the Regents and Governors in the coming year for the purpose of amending the bylaws of the College. He wrote that, in his opinion, if the College was to continue its constructive work in the future, it would be necessary to have the governing bodies interest themselves more in the many activities of the College and to have each member assume more 324 Fellowship of Surgeons of the responsibilities of his appointment. He said that he recognized that due to his long encumbency as Director General and to his intimate knowledge of the problems of the College, there had been a tendency to delegate these responsibilities to him. While he remained Director General, the administrative staff and the governing bodies could hardly be expected to assume these responsibilities and initiate actions. Therefore, he would resign his office to take effect immediately after the annual meeting of the College the latter part of October 1935. Some of the Regents, he said, were insisting that their resignations from the Board be accepted in the near future since they had served from the founding of the College. He had taken the liberty, he wrote, of asking the Chairman of the Board of Regents to appoint a committee to study the problem and, in co-operation with the Regents, to present a report for action at the midyear meeting of the governing bodies. The reactions of members of the Board of Regents were sincere, sentimental and heart warming to a man like Martin. J. Bentley Squier wrote, "To think of the American College of Surgeons without you in any position, other than Director General, almost makes me feel that the world is indeed a different place to live in, compared to what it used to be. . . . The next twenty-five years, in all probability will be ones of great changes in medical economics and . in academic thought and I am not so sure that those who live through them will make glorious contacts of friendship which have made your life and mine so complete." C. Jeff Miller wrote, "Whatever we may all think about it, the College has been your baby from the beginning and the ultimate success of the College will be through and because of the early work of organization and fixation of standards that emanated from your mind." Robert Greenough, who had worked hard to support and further the programs of the College in a professional atmosphere of hostility to the organization, stated, "There is obviously no one individual who could in any way take your place. Anything I can do that will contribute in any way to make this move Fellowship of Surgeons 325 of yours more comfortable for you, or to diminish its inevitable disruptive effect upon the organization, which you have worked so many years to perfect, I shall be proud to do." Samuel C. Harvey, a Regent representative of men in the Eclat Club and the Society of Clinical Surgery who had been outspoken in their criticism of Martin, expressed a more factual reaction. "I am very glad to have the information conveyed in your letter of December 29 concerning the plans for the possible changes in the organization of the College. I should like to heartily congratulate you upon the generous and broadminded attitude which you take concerning this. It has, of course, been necessary during the formative period of the College to have a highly centralized and authoritative leadership. In fact, of course, every one realizes that it could scarcely have been done without you personally exercising such leadership. I believe with you, however, that the time is ripe for a judicious distribution of responsibility and that the plans must be carefully worked out for such." Franklin Martin went to Phoenix immediately after the first of the year in 1935, and Mrs. Martin joined him there in the middle of January. Characteristically, he began to work vigorously at the job of retirement. He insisted that he was having the time of his life getting rested in Phoenix at the Arizona Biltmore Hotel. He wrote, "It has been with a feeling of great relief in a way, that finally I have had the nerve to do what I felt I should have done for the last six years, and in reality, I had contemplated doing this at each annual meeting for a period much longer back than that, but each time, some disturbing element occurred that made me feel that I should wait for a better day. These changes are hard to anticipate but there is a certain satisfaction in having made up our minds to the inevitable and I am quite sure that the inevitable will be a bed of roses and I hope a well-earned satisfaction." The committee of the Regents adopted the suggestions made by Martin and quickly approved the appointment of an administrative board to consist of Malcolm MacEachern and Bowman 326 Fellowship of Surgeons Crowell, Associate Directors of the College; Albert D. Ballou, General Manager of The Surgical Publishing Company, Marion T. Farrow, executive secretary, and Eleanor K. Grimm, Martin's secretary, who was named secretary of the board. During his vacation, Martin carried on an active correspondence and many telephone conversations concerning the threat of the federal governmental control of medicine. While at lunch one day during the last week in February, he had an attack of severe pain in his chest. Without saying anything to his wife, he left the table and went to his rooms on the second floor of a cottage some distance away. Franklin Martin had suffered a coronary occlusion. Despite angry and forceful objections, he was taken several days later to St. Joseph's Hospital in Phoenix where he died on March 7, 1935. There was one question uppermost in the minds of those loyal and interested men deeply concerned with the purposes and ideals of the American College of Surgeons. Was it now so firmly established in the surgical world that it could withstand the loss of such a dynamic leader? CHAPTER 10

T A SPECIAL meeting on April 6, 1935, one month after Franklin Martin's death, the Board of Regents took stock ofA the American College of Surgeons. They found many accomplishments in 22 years. Yet, they were mindful of Martin's warning that the College would not go forward without an energetic, imaginative, enthusiastic and faithful Director. The hospital standardization program had been an unqualified success. More and more hospitals were improving their facilities and services to gain the coveted stamp of approval from the College. The American Hospital Association had co-operated fully in the program and was rapidly offering greater assistance to its members in solving problems of administration. The American Medical Association had belatedly joined the procession and constantly pressed for a joint effort with the College. The expense of inspection and administration of the hospital standardization project had increased proportionately with its acceptance. The cost to the College was becoming a worry to the Regents. Nevertheless, the Regents restated their belief that since this work was such an integral part of the activities of the College, the hospital approval program should always be kept in its hands. They believed that continuity would be destroyed if an attempt were made to apportion any part of the work to another organization. The Regents had instructed MacEachern to support and encourage other organizations to do everything they wished because there was plenty of work for all. MacEachern emphasized the close relationship and understanding which existed among the representatives of the organizations interested in hospitals. He reiterated his opinion that the American Medical 828 Fellowship of Surgeons Association was interested primarily in the education of interns in hospitals. The Committee on the Treatment of Malignant Diseases had worked vigorously since its inception. Record forms for reporting results of the treatment of cancer had been adopted widely. Uniformly gathered statistics, which would shed some light on the cancer problem, could at last be compiled from a large number of institutions. Cancer clinics were surveyed continually by the College staff, and of the 250 which had been evaluated, 198 had been approved. Over a hundred additional hospitals had indicated that they were in various stages of forming cancer detection clinics. In these clinics, patients could be reasonably assured of a complete examination, accurate diagnosis, group opinion, accurate records and the best treatment which could be offered in the community. Many problems had arisen in the selection of trained personnel to staff the clinics, assure proper equipment and maintain effective administration. With the help of the American Society for the Control of Cancer, however, great progress had been made. In addition to the beginning realization by the laity that cancer could be treated, perhaps the greatest contribution had been acceptance by the medical profession of the necessity for joint effort of the surgeon, pathologist, radiologist and internist in order to arrive at an accurate diagnosis and outline effective treatment. At the last three Clinical Congresses, a symposium had been held on the curability of cancer based upon the report of almost 25,000 patients who had survived five years following surgical treatment. From such conferences, it was anticipated that information could be gathered for the guidance of the medical profession concerning accepted methods of treatment for cancer of various organs of the body. The early efforts of the American College of Surgeons and the American Society for the Control of Cancer in another 20 years were to result in one of history's biggest efforts to over- Fellowship of Surgeons 329 come a major disease. The Federal Government added funds and established a cabinet department to organize hospitals, universities, research laboratories and industry in a full-scale search for cancer-destroying drugs. Forty thousand substances tested for anti-cancer properties and the expenditure of about $30,000,000 in 1958 was a goal which could not have been imagined. The bone sarcoma registry had gathered detailed data on 1,880 patients. It was decided that when the 2,000 mark was reached, the registry should be discontinued. This would be a sufficient amount of material for study from which to secure the results of treatment. It was suggested that another registry of rare tumors in the body could be initiated later. 1 This had been the first scientific project of the new College. Quite justifiably, the older Regents had a warm place for it in their affections. The Committees on Fractures and Industrial Medicine had exerted a profound influence upon the care of the injured individual, wherever the accident occurred. Through the combined efforts of the College, the Red Cross and the Boy Scouts, the public was being educated about the importance of the immediate care of the patient with fractured bones. First aid kits were designed, traction splint apparatus was approved and concise pamphlets easily understood by the layman were distributed. Subcommittees and regional groups were formed from the Fellows who gave generously of their time to appear before groups of interested laymen and physicians. Industrial organizations had modernized their medical facilities and in many instances had finally been stimulated to inaugurate services for

1 All of the records and microscopic slides of over 2,200 cases in the bone sarcoma registry were turned over to the Armed Forces Museum of Pathology by the American College of Surgeons in July 1953. This disposition of the results of a pioneering effort by pathologists, radiologists and surgeons to effect a co-ordinated study of a puzzling group of tumors was recommended by a subcommittee of the Committee on Cancer, under the chairmanship of Ian Macdonald of Los Angeles. 330 Fellowship of Surgeons their employees injured at work. These activities by an enthusiastic and energetic group of Fellows called for the appropriation of money to help defray expenses, which to date had largely been paid from their own pockets. The library facilities of the College were expanding. Reprints, abstracts and bibliographic references on surgical topics were furnished to the Fellows in packages mailed to them on loan. The development of surgical motion picture films, inaugurated in 1929, was progressing slowly but surely. Films were sent on loan to Fellows for their use in teaching. George Crile continued to promote the erection of a multi- storied Hall of the Art and Science of Surgery on the new property acquired by the College. He had influenced an archi- tectural firm to submit sketches and floor plans for a building seven stories high with 10-foot ceilings and 52,500 square feet of space. So that the exhibit rooms in the basement and the first five floors would have more room for displays, no windows were to be installed. The remaining two floors would be preparation rooms. The building would be of Indiana limestone with black granite on the first floor. It was to be equipped with elevators and circulating washed air. The cost would be $140,000 for a living museum of the evolution of diseases of various organs. The Regents listened politely and seemed interested, but Crile was disappointed that no one of them joined him in his efforts to add to the exhibits for the hall. He continued, however, to send wax models of the hearts, adrenal glands and other organs of elephants, lions and smaller animals to the Col- lege for an exhibit of comparative anatomy to be linked with the attributes, habits and characteristics of each species. The annual Clinical Congress continued to be a successful method of providing postgraduate instruction for the Fellows. Sectional meetings were gaining in popularity. These scientific meetings served as examples of the best organized medical gatherings. Visitors from Great Britain, Australia, New Zealand, South America and the Scandinavian countries increased in number each year. Gradually, the pendulum was swinging more Fellowship of Surgeons 331 and more to the United States and Canada as sources of the most advanced surgery and surgical teaching in the world. No direct loss had occurred in the Endowment Fund securities of the College which amounted to $868,281.49, but there had been about 12 per cent shrinkage in the value of the investments. The Regents had approved the loan from the Endow- ment Fund to finance the purchase of the property at 650 Rush Street, as Franklin Martin had recommended. Part of this borrowed money had been paid back from a portion of the Fellow- ship fees and other income until the outstanding debt was reduced to $170,000. The Endowment Fund was not regarded as a trust fund but was created for the use of the College in any way the Regents might see fit. The College now owned the entire north side of Erie Street between Rush and Wabash (Cass) and a sizeable portion of the south side. Criticisms about the use of the College funds and charges of lack of audited reports had finally disappeared solely because of their picayunish paltriness. After proper investigations and hearings were conducted, the Regents had continually taken action, without publicity and in an effort to save the involved Fellow its effects, which led to expulsion from Fellowship. Fee-splitting, advertising and other unethical and unprofessional practices were the usual charges brought against the offenders. Because the Regents took action quietly, unfounded statements that no Fellow was ever expelled regardless of the charges were constantly being made. The Regents knew that if candidates for Fellowship could be selected wisely, fewer Fellows would come before them for judicial action. The continued success of the College depended upon that principle. The methods of selection had been improved by constant study through the years. Problems had been numerous in larger communities where many candidates applied for Fellowship. It was difficult to obtain adequate information so that each applicant could be dealt with judiciously, to the best interests of the College and to the satisfaction of the local committee on credentials. 332 Fellowship of Surgeons In various areas, the Regents had authorized the credentials committees to establish committees on applicants composed of eight Fellows who served as a local fact-finding group. These men interviewed each candidate, secured all the information about his training and surgical practices and presented it to the credentials committee. Each committee on applicants was instructed by the Regents not to usurp the prerogatives of the credentials committees. They were to find the facts, correlate them and present them without recommendation to the credentials committee. No new standards for applicants should be introduced, and each member was to observe the injunction not to inform the candidate of any action taken. Gradually, the committees on applicants proved to be of great value in adjudicating the differences, which became bitter and ingrained, when applicants for Fellowship continued to be refused a recommendation by the credentials committee. It gave the Fellowship, now 11,581 in number, a greater feeling of participation in maintaining the standards for Fellowship which they themselves had attained. Dramatic moments and words of bitterness had appeared in the Regents' meetings over the application of Louis T. Wright, a colored surgeon from New York City. The arguments advanced pro and con had been exactly the same as those given when Daniel H. Williams had been included among the list of initiates at the first meeting of the College in Chicago in 1913. Was the candidate professionally and ethically qualified? The answer to this question alone should be the determining factor, it was said. "This is true," said the southerners on the Board, "but there are social gatherings of the College at which our Fellows cannot accept a Negro." In spite of these objections, Louis T. Wright was the second Negro to obtain Fellowship in the American College of Surgeons. Following this, applications were received from other Negro surgeons, many of whom were not as well qualified as Wright. Objections continued to be raised by the southerners of the Fellowship of Surgeons 333 College, and many northerners accused the Regents of exhibiting racial discrimination. Some years later the Regents appointed a committee to prepare a report on this subject. Henry W. Cave, a younger Regent born in Kentucky, served as chairman. The other members of the committee were Alton Ochsner, a South Dakotan transplanted to New Orleans, and Frederick A. Coller, a North Dakotan educated in the east. Henry Cave visited Louis Wright in his hospital, office and home. Cave also accepted invitations to address groups of colored doctors in New York City. The report of the committee, which was mainly the work of Cave, recommended that all applications from Negroes be considered solely upon the applicant's surgical training, abilities, professional ethics and practices; in other words, just as any other surgeon. These recommendations were adopted by the Regents after an emotional outburst from James M. Mason of Birmingham, Alabama. It is interesting to note that the first colored surgeon from the Deep South came from Alabama in 1946 when James Mason was the chairman of the local credentials committee in that state. The question of admission of colored surgeons into the American College of Surgeons was settled for all time. The administrative board had been activated at the April 1935 meeting of the Regents immediately following Martin's death. In October 1935, Charles Mayo and John Finney submitted their resignations as Regents to provide vacancies for younger surgeons. Both had served from the beginning and had been staunch supporters of the principles upon which the Col- lege had been organized and of its methods to accomplish its goals. Finney's support had been shaky at first and he had listened to the many pessimistic voices of his colleagues in the East. As his experience grew and the years went on, his loyalty and support attracted many doubters into Fellowship. Franklin Martin's will provided that upon the death of his wife, all of the stock of The Surgical Publishing Company would become the property of the American College of Surgeons. On 334 Fellowship of Surgeons October 28, 1935, Isabelle Martin assigned, transferred and conveyed these shares to the College as trustee. The Regents accepted this trust with the provisions which she stipulated. Isabelle Martin would receive the entire income from the stock during her lifetime. Upon her death, the trust would cease and the College would become sole owner of the stock. Surgery, Gynecology & Obstetrics would remain the official publication of the College, which would use its best efforts to maintain and develop the journal as an effective instrument in the advancement of medical and surgical science. Certain Fellows of the College would be appointed to render assistance in the editorial and financial management of the surgical journal. Finally, it was stipulated that the words "Franklin H. Mar- tin, M.D., Founder-Managing Editor 1905 to 1935" should be carried on the cover and at the head of the editorial page. If the journal should be published under any other name or in connection with any other magazine, a suitable legend should be carried in memory of Martin. Any property owned by The Surgical Publishing Company and any building developed upon that property in which the activities of the College would be carried on should be known as "The Franklin H. Martin Memorial." All of these were great accomplishments upon which the Regents looked with satisfaction. They had reason to believe that under the organization of an administrative board and without a dynamic Director future progress might be slow, but it would be steady. From the beginning, the yardstick to be applied to candidates for Fellowship regarding their training to be surgeons had been a continual subject of discussion and debate. Franklin Martin had hoped that the College could stimulate medical schools and universities to place their own stamp of approval upon surgeons who successfully accomplished the training program outlined by their institutions. He believed that once this started, methods of approving similar programs carried on at hospitals not connected with teaching institutions could easily be developed. Fellowship of Surgeons 335 Martin's suggestion would have kept the approval of the training of surgeons as the right of medical educational institutions. In the organization and development of the American College of Surgeons, men without formal surgical training equal to that offered by only a few institutions at the time, were made Fellows. This fact overshadowed this fundamental part of Mar- tin's original proposal. In fact, critics of the College were not aware of this statement of a goal to be reached, nor did they take the trouble to find out. The Clinical Congresses were designed to continue the education of the surgeon. From the beginning, the Regents had also concerned themselves with the problems which surrounded the education and training of the recent medical school graduate to become a surgeon. During the preceding 20 years John G. Clark, William J. Mayo, Rudolph Matas, John B. Deaver, Harold L. Foss, J. Bentley Squier, Allen B. Kanavel and William D. Haggard had spoken and written about the education of the surgeon and his preparation for a surgical career, utilizing the approved hospital as a medical education center. 2 It was in the area of influence to be exerted by the Committee on Graduate Training for Surgery, appointed on October 19, 1934, that the Regents believed the absence of a Director General would be most keenly felt. Samuel C. Harvey was named chairman because he had received his surgical training in a formalized university medical school program. Some of the

2 Clark, John G.: Three Recent Epochs in the History of the Clinical Congress of Surgeons of North America. Surg. Gyn. Obst., 30:100, 1920. Deaver, John B.: Medical Education. Surg. Gyn. Obst., 34:177, 1922. Matas, R.: The Mission and Ideals of the American College of Surgeons. Year- book Am. Coll. Surg., 13:76, 1926. Foss, Harold L.: The Hospital Interne—Embryo Surgeon. Surg. Gyn. Obst., 53:259,1931. Mayo, William J.: The Education of the Surgeon. Yearbook Am. Coll, Surg., 16:147, 1926. Squier, J. Bentley: Fundamentals of Specialism. Yearbook Am. Coll. Surg., 20: 142, 1933. Haggard, William D.: Preparation for a Surgical Career. Bull. Am. Coll. Surg., 17:3, 1933. Kanavel, Allen B.: The Standardized Hospital as a Medical Education Center. Bull. Am. Coll. Surg., 16, 4A:9, 1932. 336 Fellowship of Surgeons Regents expressed doubt that Harvey was aggressive enough to retain the initiative displayed by the College when Franklin Martin's motion was adopted to establish the committee to study the question of graduate training for surgery. Acceptances to serve on the committee were received by January 1935, and at the April meeting of the Board of Regents a preliminary report was given by Harvey. He called attention to the fact that active discussions of the topic of graduate surgical training were to be undertaken during the spring meetings of the American Surgical Association and the Section on Sur- gery of the American Medical Association. He announced that it was therefore deemed wise to hold action by his committee in abeyance until the tenor of these discussions became apparent. A symposium of the graduate teaching of surgery was held at the American Surgical Association meeting in the spring of 1935. Papers on the subject were given by Elliott C. Cutler, George J. Heuer and Allen 0. Whipple.3 Following the discussion of these papers, a resolution was adopted empowering the president, Edward W. Archibald of Montreal, to appoint a committee to meet with representatives of other responsible surgical organizations for a consideration of the problem. Evarts Graham was chairman of this committee of the American Surgical Association, "To Study Further Problems of Postgraduate Surgical Education in General and the Qualifica- tions for Specialization in General Surgery in Particular." The committee met without delay to pass a resolution proposing the formation of a joint national committee to discuss and arrange a program for accomplishing "the elevation of standards of the practice of surgery and to increase the hospital facilities for the training of young surgeons." The proposed joint committee was to consist of 24 members; six each from the American College of Surgeons, the American Medical Association and the American Surgical Association and

3 Each of these men had been a member of the committee appointed by the Regents in 1931 to study undergraduate, graduate and postgraduate teaching of surgery. Fellowship of Surgeons 337 two each from the Western Surgical Association, the Southern Surgical Association and the Pacific Coast Surgical Association. The resolution ended with the sentence, "It is hoped that the American College of Surgeons will co-operate in the proposed endeavor by appointing six members to serve on the national committee to organize this work."4 This committee of 24 met on October 23, 1935, in Chicago, with representatives of the College present. The resolution was submitted formally as an invitation to the College to act in conjunction with the proposed national committee. Immediately thereafter, Harvey's committee met and submitted the report of their deliberations to the Board of Regents at a meeting on October 29. The report defined graduate training in surgery as excluding that teaching which precedes the granting of the degree of doctor of medicine and that which occurs after a doctor has been qualified as a surgeon. The term was confined specifically to the period when the graduate in medicine is being trained in the art and science of surgery so that he may be qualified as a specialist in that field of medicine. In an attempt to determine the trend in training through the years since the College was founded, Harvey's group wished to have an analysis made of the applications accepted for Fellow- ship in 1935. They established two broad principles which they believed could not be disassociated, the methodology of teaching surgery and the methodology of ascertaining that such teaching in the individual case had been effective. Harvey's committee stated that a surgeon could receive the necessary training by two methods. The first, a more systema- tized and formalized program, as carried out in certain universities, in some instances led to distinctive degrees indicating that the student had achieved adequate proficiency as a surgeon. The second method was a less systematic type of instruction which was received through an apprentice form of training. The first method must include within it a large amount of firsthand experience with patients and the technical procedures

4 From Minutes, Board of Regents, October 29, 1935. This group would be known as the National Committee for the Elevation of the Standards of Surgery. 338 Fellowship of Surgeons peculiar to surgery. Since many educational corporations of varying standards of performance and integrity were legally entitled in the various states to grant degrees, it was recommended that the College should recognize approval only from those medical schools rated as Grade A by the Council on Medical Education and Hospitals of the American Medical Association. Standards of plant facilities, personnel and organization should prove adequate upon inspection to provide proper training in surgery. This program of surgical training under the control of competent educational institutions was admittedly the most desirable, but there were not enough such places to train a sufficient number of surgeons to meet the needs of patients over the country. It was necessary, therefore, to consider the forms of training by means of which the majority of surgeons practicing had gained distinction to see if those methods could be improved. The College had emphasized the need of more surgical training than that received in a hospital internship. Its requirements reflected this concept in that an applicant for Fellowship could not be considered until after completion of at least seven years of formal training and experience in surgery following graduation from medical school. The crux of the discussion was how further experience in surgical training could be gained. A time-honored method had been to enter into partnership with or to serve as a salaried assistant to an older and experienced practicing surgeon. Oc- casionally, this proved to be an admirable form of training, but it depended upon how well the senior kept himself competent and whether or not he possessed an ability and desire to pass on knowledge to his junior. The committee stated that this was not the preferable method of procedure for the training of young surgeons. However, this was not the most commonly used method. Armed with his state license, the recent graduate aspiring to perform surgical operations simply entered general practice and gained experience from his patients. More recently, some Fellowship of Surgeons 339 medical school graduates had spent one or two years as an intern in a hospital where they had participated in operations. In some communities, isolated from medical centers, it was necessary for the doctor to perform surgery. From such circumstances, competent surgeons worthy of recognition had occasionally developed. The economic aspects of such environments militated against the support of the services of a fully qualified man who wished to devote himself solely to surgery. They also provided excellent culture media for the growth of fee- splitting. A third method of receiving training and one which had been increasing was to appoint a young man to the associate or adjunct attending staff of a hospital. Such men were not resident in the hospital but carried on their own private practices. It was hoped they would receive teaching and experience from the senior staff. But more often than not, the personnel, organization and hospital facilities were below standard and the senior men were interested in having helping hands rather than in training a young man to become their competitor. The training of surgeons in teaching hospitals associated with medical schools was by far the most desirable program to be followed. This meant that the trainee lived in the hospital with his patients; he was a resident surgeon in training. It was agreed that the opportunities for obtaining this type of surgical training were too limited and would remain so as long as such programs were limited to medical school hospitals. Therefore, resident training programs would have to be established in hospitals which could be approved for that purpose. The committee emphasized another facet of surgical training. Every program must include the further study of the fundamental sciences of anatomy, physiology and pathology. In addition, the trainee should have a comprehensive knowledge of the surgical literature. This added requirement posed the question of how to provide this part of the surgical education in a hospital not affiliated with a medical school. The committee and the Regents believed that among all surgical organizations, the College was particularly suited through 340 Fellowship of Surgeons its hospital standardization program to survey and continue the inspection of resident training programs. This was a fact accepted by the National Committee for the Elevation of the Standards of Surgery. The American Medical Association's Council on Medical Ed- ucation and Hospitals had devoted its interest to the character of the internship provided in hospitals but had never initiated the extension of residency surgical training in hospitals. The American College of Surgeons was a necessary and integral part of any program which aimed to increase the unanimously accepted preferable method of training surgeons, if the programs were to be kept at a high level. The second principle was one which could be assumed by another mechanism outside the College. In fact, its establishment by another agency would set the pattern of the qualification of future candidates for Fellowship and at the same time would constitute a vigorous criticism of the existing standards of Fel- lowship. This criticism had been stated and re-stated by the Eclat Club, the Society of Clinical Surgery and Evarts Graham's presentation to the Regents of the results of his personal questionnaire. The principle was really a question. How to ascertain the effectiveness of such educational residency training programs in each individual instance? State medical licensing boards varied tremendously in testing the fitness of medical graduates to practice medicine. Every attempt to raise these standards had met with vigorous opposition and had failed. It was claimed that federal licensure violated the principle of states' rights. To establish standards for licensure in each state for the practice of surgery as a specialty of medicine appeared hopeless on the face of the proposition. The experiences of the National Board of Medical Examin- ers, an independent non-licensing group whose examinations had been accepted by several states, had encouraged the establishment of examining boards in certain specialties of medicine. The ophthalmologists, followed by the otolaryngologists, had been the first to organize such boards. Other specialties Fellowship of Surgeons 341 were following their lead, and an Advisory Board of Medical Specialties had been established to determine minimum standards. Representatives from several organizations in each of the specialties had formed these boards and functioned under the aegis of the Council on Medical Education and Hospitals of the American Medical Association. It was a natural step to form the American Board of Surgery, and Harvey's committee recommended to the Regents that the College co-operate in the formation of such a board. Kanavel and C. Jeff Miller, who had been active in the College for many years, insisted upon the introduction of a qualification to this recommendation. It is not, however, proposed that the College shall in any sense abrogate its right to determine the fitness of the candidates for its Fellowship. While the diplomates of such an examining board of surgery might be given the same consideration as obtained with those of Ophthalmology, Gynecology and Ob- stetrics, Oto-Laryngology, Orthopedics, Urology and Radiology, the membership in the College cannot be limited or ensured by an extraneous board. Special consideration must be given to attributes difficult to ascertain by the methods so far set up by these boards, such as judgment, integrity and personal fitness. In the end, the College itself must adjust its qualifying procedures so as to test the adequacy of any program for the graduate training for surgery which it sees fit to endorse. Your committee, therefore, recommends that in conjunction with the development of a program for the graduate training for surgery a restudy be made of the requirements for admission to Fellow- ship in the College. The Board of Regents did not oppose the formation of the American Board of Surgery. Concern was expressed, however, over the possibility of lessening the influence of the American College of Surgeons upon the elevation of the practice of surgery, a primary objective of the organization since its inception. This concern was fostered by a lack of clear definition of the participation of the College in the proposals to direct the training of young surgeons. Some individuals were suspicious of 342 Fellowship of Surgeons the motives of Graham, Elting, Whipple and other members of the Eclat Club and the Society of Clinical Surgery who had been hostilely critical of the College. A degree of antagonism existed between surgeons in practice who voluntarily gave their time to teach medical students and those who received their remuneration from medical schools and hospitals for teaching duties. Misunderstanding resulted over the meaning of graduate and postgraduate training, and certain Regents assumed that a certificate obtained by a written and oral examination would be considered of equal importance to Fellowship in the College. Malcolm MacEachern attempted to analyze the problem for the Regents. He emphasized that graduate study in surgery should not be confused with postgraduate study, which is the further pursuit of an already acquired discipline in surgery. Surgical training could not be carried on solely in a classroom or laboratory but required actual participation in the care of the patient. In a sense, the hospital surgical beds constituted a laboratory. Neither should the continued study of anatomy, physiology, pathology and allied subjects, particularly as they affected the surgical patient, be neglected. MacEachern then turned to the approach which had become the hallmark of the work of the College. A definite minimum standard for training in surgery, which would define in detail the program of study to be followed in a three or five-year residency, should be established. Regular surveys by a member of the College staff or by a committee from the institutions concerned should be carried out. Such a committee could be responsible for the grading of residency programs and the maintenance of standards. He recognized the existence of training programs already established in university teaching hospitals and supervised by the department of surgery of the medical school. On the average, these were five years in duration, available to only a few and for the most part embraced general surgery to the exclusion of the surgical specialties. The College should actively encourage the inauguration and development of similar residency graduate studies in other medical schools. Fellowship of Surgeons 343 MacEachern called attention to the surgical training offered by a few outstanding clinics but they, too, were few in number. There might be other clinics where training in surgery and the surgical specialties could be carried on as it was at the Lahey and Mayo Clinics. The largest opportunities for training surgeons were in certain outstanding hospitals, approved under the hospital standardization program, where plans for a three- to five-year residency in general surgery or the surgical specialties could be organized at once. There were 113 such hospitals, MacEachem said, and approval could be given to their training programs as they met the established proper standards. At the annual meeting of the American Surgical Association in the spring of 1936, Evarts Graham presented a report from the National Committee for the Elevation of the Standards of Surgery. The report detailed suggestions for the organization of an American Board of Surgery. It defined the eligibility of candidates for examination, the type of examination and its content, the fees to be charged and ways and means of en- larging the existing facilities for the training of surgeons. The American Surgical Association, the Pacific Coast Surgical Association and the New England Surgical Society had approved the recommendations and appointed their representatives to the Board. It was contemplated that the American Board of Surgery would be functioning early in 1937. Approval for the establishment of the American Board of Surgery had been obtained from the Advisory Board for Medical Specialties on February 16, 1936. To have the Board organized and functioning, the leading spirits of the national committee had ruled that all of the members of the American Surgical Association, the Southern Surgi- cal Association, the Western Surgical Association, the Pacific Coast Surgical Association, the New England Surgical Society and the professors, associate and assistant professors in all Class A medical schools in the United States and Canada would automatically become members of the founders' group. It was specified further that during the first two years of the Board's exist- 344 Fellowship of Surgeons ence, those who had limited their practice to surgery during the preceding 15 years could apply and be certified without examination. When these recommendations in the report became known, many of the Regents took heart, recognizing the human weaknesses of some of their younger colleagues who had heretofore appeared arrogantly scholarly and infallible. The criticisms previously directed at Martin and his contemporaries for their methods in organizing the American College of Surgeons had been conveniently forgotten by Graham and his colleagues. At the meeting of the Regents on May 10, 1936, Crile called on MacEachem to read in detail the plans which the Regents could adopt as the policy of the College in the field of graduate training in surgery. MacEachem amplified his original presentation. The character of the candidate was summarized in one word —honesty. His preliminary and medical educational requirements were spelled out. He should have served a rotating internship of 18 months in a hospital approved by the American College of Surgeons and for intern training by the American Medical Association. The surgical residency should extend over a minimum of three years. If the candidate was interested in a surgical specialty, he should have at least one year of training in general surgery. The requirements for the hospital or clinic to meet the minimum standards were equally detailed. A well-organized medical staff with chiefs and heads of departments of recognized standing and teaching ability, surgical conferences at least weekly in which the resident actively participated, clinico-pathological conferences and active and personal supervision of the residents' training were essential for approval. MacEachem's plan proposed a local advisory committee on graduate training in surgery. The local group would include three Fellows of the College, approved by the Executive Com- mittee of the Regents and the administrative board of the College. This committee would direct and insure systematic Fellowship of Surgeons 345 training and maintain personal supervision through a preceptor appointed to guide each resident. The plan scheduled the daily hours of study, the number of patients on the surgical service to which the resident would be assigned, the number of autopsies upon patients dying postoperatively, perusal of the surgical literature and anatomical dissections on cadavers and animals. All of these activities were to be recorded by the resident and submitted each month to his preceptor for evaluation and filing. An annual report of these monthly summaries would then be sent to the American College of Surgeons for review by the central advisory committee on graduate training for surgery. Each candidate would be required to spend a supplementary six-month-period away from his parent hospital. During those months, he should observe surgery in other hospitals or clinics, make a special study of a surgical problem or engage in a research project. At the completion of the residency, an examination consisting of a thesis and/or written or oral scientific and clinical questions would be given by the local advisory committee. After passing the examination, the young man would receive a signed statement from the central advisory committee on graduate training comprehensively summarizing his training. Such reports would serve a further purpose in helping evaluate the standard of the training given in each hospital or clinic. Every institution selected for graduate training in surgery would be surveyed at regular intervals by delegated officials of the American College of Surgeons. The resulting reports and all other essential data would be considered by the central advisory committee for graduate training in surgery, and a list of the institutions meeting the requirements would be published annually. MacEachern's report recommended that the College should provide the funds for the administration of the plan until they could get money from other sources. The existing budget for the hospital standardization program could carry the cost of the first 346 Fellowship of Surgeons surveys. The hospitals or clinics would have to offer living expenses for the trainees and, if possible, a small additional stipend. Efforts to obtain support from an educational foundation should be pressed vigorously. MacEachern laboriously read his report word for word, including the name of each of the 113 institutions which could be approved immediately. He submitted sample blanks for hospitals and clinics to fill out in applying for approval as a training institution. Finally, he introduced a lengthy resolution embodying all of these details and calling for action by the Regents on each resolution. The final paragraph called for authority from the Regents to the Executive Committee to appoint representatives of the Col- lege to meet with committees from other organizations also interested in the problem of graduate training in surgery. All of the plans under consideration could then be co-ordinated. The Council on Medical Education and Hospitals of the American Medical Association, the Association of American Medical Col- leges and the Canadian Medical Association were the organizations singled out. When Crile asked the Board of Regents to consider the resolution, Franklin Martin was absent for the first time in the history of the American College of Surgeons when an important issue was at stake. His absence was felt. Judging from the record of his performances, he would have prevented MacEachern from presenting such a mass of material to the Regents at one time. He never would have made such a tactical error had he desired to propose a plan for control of graduate training in competition with that already approved by other surgical organizations. It is doubtful that he would have asked the Regents to appoint a committee to co- operate with other organizations until it was quite obvious that such a plea was necessary for the successful carrying out of the plan. The strength of the American College of Surgeons in any plan to elevate the graduate training programs in surgery resided in the fact that it already had a mechanism to evaluate Fellowship of Surgeons 347 proposed residency training programs through the surveyors employed in the hospital standardization project. It would be extremely difficult, if not impossible, for the proposed Ameri- can Board of Surgery to do this alone. The weakness of the College rested solely upon the failure of the Regents to agree on a method of determining the fitness for Fellowship of those who had graduate surgical training. None of the plans proposed by Edward Martin and stimulated by Franklin Martin had ever been satisfactory to them. Frank- lin Martin had insisted again and again that the medical schools and certain hospitals should be accorded the right of declaring that their trainees had fulfilled all of their requirements to be a surgeon. In this respect, Martin had said that such institutions should be looked upon as colleges and universities who confer degrees in course. The Regents agreed that the American College of Surgeons should co-operate to the fullest in the formation of the Ameri- can Board of Surgery and asked their Chairman to name three representatives to the Board. 5 Considerable doubt was expressed that establishment of the Board would solve the problem of graduate training in surgery. Several Regents objected to the specific details outlined in MacEachern's presentation, believing as Greenough did that broader terms should be used to express the goals sought. The Board of Regents would not be obligated to accept standards formulated by the American Board of Surgery for its candidates for Fellowship. Harvey emphasized this point. The Col- lege must continue to establish its own qualifications for Fellow- ship which might differ in stringency from the requirements of the Board. He hinted that it was necessary that the College co-operate for the Board to be launched successfully, but Harvey was not a forceful leader. He was, however, a useful liaison. Harvey argued against the suggestion that the Association of

5 The first three men appointed by the American College of Surgeons to the American Board of Surgery were Donald Guthrie, Sayre, Pennsylvania; Erwin R. Schmidt, Milwaukee, Wisconsin; and Harvey B. Stone, Baltimore, Maryland. 348 Fellowship of Surgeons American Medical Colleges be represented on the Board. It was not contemplated, he said, that the Board be an educational body. Howard Naffziger expressed his concern over the tendency of some of the existing boards to dip into educational problems and to specify that educational institutions do certain things, particularly since the boards were not composed of individuals who were familiar with educational problems. He, personally, was not pleased with attempts to standardize premedical and undergraduate medical requirements. Nor was he particularly anxious to standardize graduate training in surgery or in the surgical specialties. In essence, Naffziger supported Franklin Martin's thesis of dependence upon educational institutions and the development of hospitals, unconnected with medical schools, as teaching centers under established requirements. Samuel Harvey and Eugene Pool used Naffziger's arguments against the adoption of MacEachern's detailed proposal but were willing to agree that the report should be approved in principle. A flexible plan, which would permit a full discussion of details of methodology later as the Board began to function, would allow the spheres of influence of the College and the Board to become delineated more clearly. After agreeing to appoint representatives to the American Board of Surgery, the Regents adopted a new requirement for Fellowship. Those candidates who graduated from medical school after January 1, 1938, would be required to present evidence of having completed three years of service in a hospital approved by the American College of Surgeons for graduate training in surgery, with two of those years devoted specifically to training in surgery. This was a policy decision which made it necessary for the College to have a practical system of surveying hospitals which it could approve for graduate training. The College could not in good faith require two years of graduate training in surgery and not attempt to increase the facilities where its prospective candidates could receive this training. Later, Pool emphasized in his presidential address that Fellowship of Surgeons 349 the unlimited facilities which existed in "non-academic" hospitals must be used for the graduate training of surgeons. 6 Even though Allen Kanavel and Frederic Besley were devoting a considerable amount of their time to the affairs of the College, George Crile had found it necessary to travel to Chicago often to consult with the administrative board. The Re- gents were asked to pass upon every paper proposed for presentation at the Clinical Congress and every individual who should be invited to take part in the program. The members of the administrative board spent many hours discussing such subjects as the color of tickets to be used at the Clinical Con- gress. They could not be accused of taking independent action. They preferred to follow the safe, tedious and laborious method since so many upsetting innovations were occurring throughout the world and even in medicine.

The rise of the Nazi party in Germany had been phenome- nally led by a ridiculous-appearing and evangelistic, shouting Austrian house painter. Mussolini was grabbing Ethiopia and flexing his military muscles. King George V of Great Britain had died. He was succeeded by the Prince of Wales, who ruled for 10 months and then abdicated in a dramatic worldwide broadcast. German troups began to reoccupy the demilitarized Rhine- land zone. Civil war was raging in Spain, and the average citizen found it difficult to decide which side he favored because the Nazis and the Russians were trying out their military equipment against each other. The automobile industry was being unionized and the United Automobile Workers of America won a strike against General Motors. ° Pool, Eugene H.: The Education of a Surgeon: Past and Present. Surg. Gyn. Obst., 64:570, 1937. CHAPTER 11

T A MEETING of the Regents, the administrative board presented a communication dated April 22, 1936, containing informationA about a proposed new surgical organization. The letterhead on the stationery read:

LE COLLEGE INTERNATIONAL DES CHIRURGIENS (Fonde a Geneve) Secretaire Tresoir Executif Prof. Dr. Albert Jentzer 8 Rue de rUniversite Geneve, Suisse The letter announced the foundation of the International College of Surgeons in Geneva and its organization in Europe. A group of regents, limited to professors of surgery at national universities, had been appointed in 62 nations. The same policy regarding the appointment of regents in the United States had been followed, the letter stated, but pre- eminent men in surgery without university connections had also been invited to hold this position. To obtain fellowship or membership, "an extremely rigid examination is prescribed including not only a written, oral and clinical examination, but also an operative surgery examination at which the candidate must perform eight operations in the presence of the examiners." The candidate would have to be known in his own country as a surgeon for 10 years before he could appear for examination. "For instance, if a surgeon desired to appear for examination for the International Fellowship degree, he would have to show evidence of being over 40 years of age and that he was licensed in his own country; that he was a member of Fellowship of Surgeons 351 his state and national societies in good standing; that he had published work on some branch of surgery or that he was a contributor of numerous articles on surgical subjects that had been published in the surgical journals of his country. . . . PP The letter was signed by H. Lyons Hunt, M.D., who regretted that he did not have sufficient copies of the prospectus to enclose in each letter but would "send for them and forward them on their arrival." The first assembly of the International College of Surgeons was to take place in Geneva, Switzerland, in August 1936. The letter was received by the Regents without comment or action. They had discussed their views repeatedly about the formation of new surgical organizations. They were well acquainted with the initial opposition to the American Surgical Association and to the formation of the College. In an answer to a Fellow's inquiry about the proposed International College of Surgeons, the Chairman of the Board of Regents wrote that any group which would strive to elevate the standards of the surgical treatment of patients, to further research, investigation and the education of the surgeon should be encouraged, not opposed. As individual members of the International Society of Sur- gery, they began to learn more about the promotion of the International College of Surgeons. The former society, with its headquarters and secretary in Belgium, numbered among its members some of the most outstanding surgeons in the world. The organization was devoted solely to the exchange of scientific facts. Members in the United States held short, informal gatherings which lasted an hour or two at a convenient time during the three-day annual meeting of the American Surgical Association. In 1936, the surgical profession of the United States was honored by the election of Rudolph Matas of New Orleans to the presidency of the International Society of Surgery. As a result of a letter from H. Lyons Hunt inviting him to be one of three Louisiana regents of the proposed College, Matas 352 Fellowship of Surgeons actively investigated the origin of the International College of Surgeons.1 He declined the invitation immediately because he believed the organization would duplicate the purposes of the International Society of Surgery, and other already established organizations, in all of its proposed reasonable functions. He also objected because he suspected that H. Lyons Hunt only represented the true founders who remained anonymously in the background. The letterhead carried the names of the officers, executive council and scientific advisory board of the American Medical Editors' and Authors' Association, impressively headed by Dean Lewis, professor of surgery at Johns Hop- kins Medical S 6001.2 In spite of Matas' letter refusing to become a regent, his name was used. He began to receive letters from his colleagues and friends abroad who were as active and interested as he in the affairs of the International Society of Surgery. After considerable correspondence and effort, Matas discovered that a Chicago doctor, Max Thorek, was active in the organization of the proposed international college. Thorek had been unable to attain membership in the International Society of Surgery or the American College of Surgeons. According to Matas, H. Lyons Hunt in August 1935 had been engaged to promote the formation of this new college of surgeons. Professor Albert Jentzer of Geneva, Switzerland, was brought into the organizational plan by Thorek at about the same time. The necessary papers indicating the formation of the college were signed and filed in Geneva on December 28, 1935. A doctor, John F. Pick of Chicago, had been sent on a recruit- ing mission by Thorek early in 1936. Pick's status was announced to Jentzer in a telegram -sent by Thorek on March 3, 1936, which stated, "Our representative (Pick) sails for Geneva." Pick interviewed several prominent European surgeons, includ- Matas, R.: Why I Object To The International College of Surgeons. Auto- graphed essay, 1952, unpublished. 2 Dean Lewis, like Graham and Phemister, had been associated in his younger days with Arthur Dean Bevan at the Presbyterian Hospital and Rush Medical College in Chicago. He, too, had thereby acquired an antipathy to the American College of Surgeons. Fellowship of Surgeons 353 ing Leopold Mayer of Brussels, secretary-general of the In- ternational Society of Surgery. Mayer wrote Matas that it was his understanding from Pick that the Rockefeller Foundation was sponsoring the projected international college with its fabulous plans for buildings, scholarships and a museum in Geneva. The International Society of Surgery had recently launched the International Journal of Surgery and Mayer hoped that some type of co-operative effort could be worked out which would allow the almost depleted treasury of the International Society of Surgery to share in the reported lavish generosity of the Rockefeller Foundation. Upon questioning by Matas, Mayer stated that Pick had informed him that he had been sent to Europe by the Rocke- feller Foundation in order to lay the foundation for an international college of surgeons. Professor deQuervain of Berne held a long interview with Pick and confirmed Mayer's assertion that Pick had made such a statement. All of these circumstances, which Matas termed malodorous, surrounding the formation of a new international surgical organization, were presented to the 44 American members of the International Society of Surgery, who met at the call of Matas and Elliott Cutler on May 8, 1936, during the annual meeting of the American Surgical Association in Chicago. A resolution was adopted stating that they emphatically protested "against the creation of a new and self-constituted international organization or project that is calculated to injure the most vital interests of the International Society of Surgery to which we belong and owe allegiance; and in furtherance of this protest all the Fellows of the International Society in the United States are urged to withhold their endorsement, support or alignment with the so-called International College of Surgeons, at Geneva, or its ramifications in the United States." The results of this action were immediate. Matas corresponded voluminously with his colleagues in Europe. He stated that Pick denied having claimed the support of the Rockefeller Foundation. Pick blamed his poor French for the misunderstanding, although he admitted that he was under the impression 354 Fellowship of Surgeons that the Foundation was backing the project. Hunt, Matas said, disclaimed the official nature of Pick's tour, saying that Pick was in Europe on his honeymoon and that he had given him letters of introduction to friends. However, as Matas pointed out to his colleagues, Pick was announced to Jentzer by a cablegram from Thorek and had told Mayer that the trip had been personally inconvenient because it had separated him from his bride of a few months. According to Matas, Thorek wrote Mayer that Pick was not his representative, although he had cabled Jentzer that he was. The entire matter was discussed at length in a business meeting of the International Society of Surgery held in connection with the annual congress of the French Surgical Association in Paris on October 5, 1936. With Professor Jentzer concurring, action was taken to caution all members of the International Society of Surgery to avoid any commitments which would align them with the proposed international college. Many prominent surgeons in the United States promptly resigned, particularly after the appearance of unsigned editorials in the Journal of the American Medical Association. Matas stated that they were written by the editor, Morris L. Fishbein, although according to the policy of that magazine, they were unsigned. Into the welter of scientific, pseudoscientific, medical and similar organizations which now appeal for the physician's patronage comes the International College of Surgeons, promoted by none other than H. Lyons Hunt, who had already to his credit (sic) the Association of Medical Editors and Authors. . . . The prospectus indicates that the purpose of the organization is to bring together in closer harmony the leaders of the various colleges of surgeons now in existence; yet there is not the slightest evidence that the colleges of surgeons in any country have indicated their willingness to be brought together by this new organization. . . . Apparently the first comers are all being appointed, but by whom and under what authority the prospectus sayeth not. . . . An invitation to membership in the present promotion might be considered more of an insult to the Fellowship of Surgeons 355 intelligence of the recipient than a recognition of extraordinary

qualifications. . . . 8 The reputation of Rudolph Matas as a scholar and the nestor of surgery in the South was firmly established. His persistence in attempting to establish the facts surrounding the beginnings of the International College of Surgeons had a great influence on the world of surgery. Based upon the facts and statements made in Thorek's autobiography, Matas concluded that Thorek conceived the idea of the organization and was responsible for its promotion and beginnings. Finally, Matas wrote, Thorek had discarded the veil of secrecy and belatedly claimed credit. It can only be conjectured what Franklin Martin's responses would have been to Thorek's proposal of an international college of surgeons. Martin and the local credentials committee of the American College of Surgeons had been confronted more than once with Thorek's application for Fellowship. But, Ru- dolph Matas carried on his fight with the help of a few surgeons whose interest in the International Society of Surgery had not lagged. The Regents were more concerned with their own affairs. In spite of Crile's frequent trips to Chicago and the presence of Kanavel and Besley, there was beginning evidence that conflict was bound to develop within the administrative board, particularly between MacEachern and Crowell. The first indication occurred when MacEachern proposed the publication of a pamphlet to be distributed to hospitals and the public. This was to state again the policy of the Ameri- can College of Surgeons on fee-splitting. MacEachem announced that he would write the text. At the Regents' meeting, Crowell questioned the project. He inquired as to the expense involved and how and where the

3 Editorial, The International College of Surgeons—Why? J.A.M.A., 106:25, 2162, 1936. Another editorial on the same subject appeared a few months later (Surgical Examinations and the International College of Surgeons, J.A.M.A., 107: 14, 1136, 1936). 356 Fellowship of Surgeons pamphlet would be published. He proposed that the Regents should approve the article before it was printed. Before the meeting ended, Crile took the opportunity to compliment the members of the administrative board on their devotion, loyalty and service to the College. This custom became a matter of record at the beginning of every succeeding Regents' meeting. The administrative board reported that the library was flour- ishing with accessions of books and old instruments. The circulation of the package material served a rapidly increasing number of Fellows in communities removed from medical centers. A committee was recommended to collect, evaluate and distribute the educational motion pictures which surgeons were having made of procedures which they had developed or found useful. Attempts to secure co-operation from the American College of Physicians in the problem of graduate training failed. It was a young organization without experience, and its Regents believed that graduate training to become a specialist in internal medicine did not present concrete questions similar to those in surgery. Through his personal friendship with W. D. Cutter, secretary of the Council on Medical Education and Hospitals, Mac- Eachern persisted in scheduling conferences between the staff representatives of the College of Surgeons and the American Medical Association. He found it difficult in the beginning because the Council expressed no interest in plans for furthering graduate training in surgery. The Council's interest in hospitals had always concerned evaluation for internship. The representatives of the College thought it would not be too great a step for the Council to become interested in surveying hospitals as proper institutions for residency training. Other problems came to the attention of the Regents. Often they had difficulty in delineating the boundaries of their efforts. Standards needed to be established for the manufacture and sterilization of catgut suture material. The influence of a large surgical organization was necessary to bring about improve- Fellowship of Surgeons 357 ments which the manufacturers agreed were desirable. By the study and work of a committee appointed by the Regents under the chairmanship of Frank L. Meleney, another significant and valuable contribution was made to the care of the surgical patient. Burt R. Shurly, a Fellow of the College from Detroit, wrote the Regents suggesting the strengthening of the membership by providing insurance protection against malpractice suits. As a group, the Regents had become somewhat reluctant to consider matters which affected the economic status of the Fellows. They agreed that this was a matter which properly should come under the jurisdiction of the American Medical Asso- ciation. Activities of the College were being financed upon a narrow deficit margin. The estimated income in the budget for 1937 was $261,500 and the actual expenditures had been $261,711. In spite of his enthusiastic nature, George Crile found the many trips to Chicago burdensome. He attempted to resign, but every Regent urged him to stay on the Board and act as Chairman until the period of transition was satisfactorily completed. Applications for Fellowship numbered 1,286 in 1937. Of this number, 558 candidates were recommended, 520 were postponed for later consideration and 208 were rejected. To increase interest in the value of patients' records, Surgery, Gyne- cology & Obstetrics awarded its seventh annual prize of a life membership in the College for the best histories submitted in support of the candidate's application. An effort was made to study some of the problems which confronted nurses in their relations with hospitals, surgeons and the educational system. The Regents appointed a committee which arranged for a joint meeting with the American Nurses Association, the National League of Nursing Education and the Division on Nursing of the Council of the American Hospital Association. One of the greatest problems was whether or not administration of the nursing service should be under the control of the administrator of the hospital. 358 Fellowship of Surgeons A movement had started to provide for courses leading to college degrees in nursing education. Such graduates would be fitted to administer the educational policies of schools of nursing and provide individuals capable of handling their own affairs free from the hospital administrator's office. It soon became apparent that the most interested parties were the nurses and the hospital administrators. Unfortunately, the committee appointed by the Regents did not take leadership in the conferences, and the relation of the nursing profession to the patient became of secondary importance. The time was ripe for doctors to help preserve the profession of nursing and still not obstruct the progress of education in nursing. The education of nurses beyond the immediate goal of providing service to the patient and hospital was long past due. When the doctors failed to assume any initiative in solving the problems raised, the pendulum began to swing to its present equally radical position where nurses may be educated beyond the desire to care for the sick patient. Another example of the attitude exhibited by the Regents since the loss of their leader, occurred with the questions arising from the increasing custom of contract ("list") practice. This procedure was entered into by doctors with many of the mining companies, particularly in West Virginia. The Medical Service Board, which had made a strong report and had drawn the fire of the American Medical Association, had been discharged by the Regents. The American Medical Association had recently established the Council on Industrial Health, to which the Regents now referred such questions. Irvin Abell, a newly elected Regent from Louisville, became Vice-Chairman of the Board in 1938 following Kanavel's un- timely death in an automobile accident. Abell was also active in the affairs of the American Medical Association and, it was rumored, was being considered as a likely candidate for president. His influence in initiating better rapport between the two organizations was great but often at the expense of the College's programs and influence. Fellowship of Surgeons 359 The relation between the American Medical Association and the Federal Administration continued to be poor. The flamboy- ant senator from Illinois, J. Hamilton Lewis, introduced a bill to make every licensed physician and surgeon a civil officer subject to prosecution in the federal courts for malpractice in special types of cases. The influence of the medical profession with the public and with the government was becoming progressively worse. The Fellowship began to sense the absence of leadership at the College headquarters. They resented the efforts of hospital lay governing boards and administrators to control surgical practices through the hospital standardization program. "What did laymen know about surgery?" they asked. "Could a governing board of a hospital refuse to reappoint a surgeon because it believed that he was splitting his patients' fees?" Why should men applying for Fellowship be subjected to the personal animosities or whims of a local group of colleagues who were jealous of the professional success of the applicants? The local credentials committees, whose names were supposed to be kept secret, were becoming powerful admissions committees which could be overruled only by the Board of Regents. Would the certificate granted by the American Board of Surgery, after successful examination, have more influence in the hands of the recent graduate, who had the opportunity for proper surgical training, than Fellowship in the College held by the older graduate who was unqualified by his formal training to take the examination of the Board? Arthur Allen, a newly elected Regent from Boston, insisted that the Governors of the College should be brought into closer touch with these questions from the Fellows and with the work of the Regents. The Governors had been neglected. They were impotent in the affairs of the College and had been looked upon as window dressing for a democratic organization too long. Allen recommended that a representative of the Board of Governors be invited to attend meetings of the Board of Re- gents. He also proposed that the bylaws be amended to state clearly that the Board of Governors should appoint a nominat- 360 Fellowship of Surgeons ing committee and elect Regents. It was an insult for the Re- gents to appoint this committee and transmit the names to the Board of Governors for their rubber stamp approval. A letter, dated June 26, 1937, and signed by the Chairman of the Board of Regents of the College, asked if the American Med- ical Association wished to co-operate in surveying and approving institutions for graduate training in surgery. An answer had not been received by the time of the Clinical Congress in Oc- tober 1937, at which the first symposium on the subject of graduate training in surgery was held. The College committee on graduate training in surgery, led by Dallas B. Phemister, had arranged the meeting which was well attended.* Finally, the answer came from the Council on Medical Edu- cation and Hospitals. The American Medical Association did not wish to participate in formulating standards for training, but its representatives would like to confer in a study of the opportunities for training. Of 3,596 hospitals surveyed in the standardization program of the College, 2,664 had been approved. It appeared logical to use the mechanism already established to form the basis of approving graduate training programs. In fact, 386 hospitals had already been surveyed and the College had approved 135 as qualified for surgical training. It was difficult for the members of the administrative board and the Regents to analyze the contradictory statements and the attitude of the American Medical Association. The war in Spain had ended, and a non-aggression pact was signed by the Soviet and Nazi Governments in August 1939. Within three weeks, Germany invaded Poland, and Russia attacked Finland. Great Britain declared war on Germany on September 3, 1939. Following their blitzkrieg in Poland, the Nazis quickly occupied Norway, Denmark, the Netherlands and

4 This committee consisted of Dallas B. Phemister, Chicago, chairman; Donald C. Balfour, Rochester, Minnesota; John R. Fraser, Montreal; Albert C. Fursten- berg, Ann Arbor, Michigan; Harry S. Cradle, Chicago; Evarts A. Graham, St. Louis; Howard C. Naffziger, San Francisco; Alexander Randall, Philadelphia; Gilbert J. Thomas, Minneapolis; Allen 0. Whipple, New York; and Philip D. Wilson, New York. Fellowship of Surgeons 361 Belgium. In spite of repeated radio protests that he was against war, President Roosevelt proclaimed a limited national emergency on September 8. The American College of Surgeons received requests from the Surgeons General of the Army, Navy and Air Force to aid in preparedness plans for mobilizing the medical profession. An infant College of Surgeons had survived World War I and had grown up, but a war greater in length and intensity would curtail activities and seriously reduce operating funds. The Regents quickly acceded to the requests of the Surgeons Gen- eral, but no specific instructions followed. At last, mainly as the result of Irvin Abell's efforts, the Trustees of the American Medical Association invited the Regents of the College to meet and discuss matters of mutual interest. There were 169,628 members of the American Medical Association, about 10 per cent of whom were self-designated in the directory as surgeons. The College Fellowship numbered 12,792. This first meeting between Trustees and Regents took place at the American Medical Association headquarters in Chicago on November 16, 1939. Fourteen Regents and staff members represented the College and 19 Trustees and staff members of the American Medical Association were present. 5 Cutter of the Council on Medical Education and Hospitals and MacEachem had agreed on an agenda. They, in turn, led the discussions. The American Medical Association registered hospitals but did not have a standardization program. Confusion in the minds of doctors and the public between approval by the College and registration by the Association hampered the program of both organizations. Cutter and MacEachem wished to have approval for the informal exchange of information which they had developed purely on a personal basis. They had agreed and recommended that there should be close co-operation between the two bodies in collecting statistics. The Regents agreed that the College should and would support the position taken by the Association 6 Minutes of the Board of Regents, November 16, 1939. 362 Fellowship of Surgeons that graduates of non-approved medical schools should not be accepted for membership on hospital medical staffs. MacEachern proposed that both organizations adopt a single statement regarding the principles of financial relations in the professional care of the patient. MacEachem had detailed 10 items, which he read to the group in the hope that a united front against fee-splitting would outlaw the practice for all time. Each doctor participating in the care of the patient, the statement read, is entitled to compensation from the patient, or other legitimate and ethical source, commensurate with the services rendered. Individual statements of the charges for the services of each doctor concerned in the treatment of the patient should be sent directly to the patient. Combined bills for doctors' services were becoming more and more common and provided an easy way to split fees. Many doctors hoped that the practice of sending combined statements would be sanc- tioned by the American Medical Association. Third parties, MacEachern's principles stated, should not enter into the financial relations between doctor and patient. Hospitals should be discouraged from determining and collecting fees for doctors. Formally organized clinics or partnerships, which in effect could be regarded in the same way as an individual, were exceptions to this rule. The practice of having the referring doctor act as an assistant or administer the anesthetic during an operation, when he was actually untrained and incompetent to do either, should be discouraged. This was another way of justifying fee-splitting. Soliciting patients either directly or through an agent, by advertising or any other means should be prohibited under all circumstances. The Trustees of the American Medical Association listened politely and agreed in principle with everything in Mac- Eachem's statement. The principles and code of ethics of their Association, they said, covered all the points raised by Mac- Eachern. They saw no necessity for giving their formal approval to another set of ethics. However, as the case had been in the Fellowship of Surgeons 363 past and would continue to be in the future, the Association is a confederation of state medical associations which, in turn, are confederations of county medical societies which are represented in the House of Delegates, the all powerful body of the Association. The Trustees, quite unlike the Regents, had no power to discipline members of the American Medical Associa- tion. Disciplinary action for violation of the code of medical ethics of the Association rested solely within each county medical society. By dissolving the Medical Service Board, the Regents indicated that they did not wish to continue debate on the question of contract practice. Many of the Regents had been chastened by the uproar in the press which the Greenough committee's report had caused.° Led by Abell and supported by Crile, the Regents assured the Trustees that henceforth such matters would be left entirely to the American Medical Association. Thus, the item on the agenda which raised the question of hospitalization insurance evoked only a unilateral discussion. Morris Fishbein, who was then editor of the Journal of the American Medical Association and commonly looked upon by doctors and the public as the spokesman and power behind the throne of the Association, said that nothing was to be gained at that moment by agitating the problem of hospitalization insurance. The entire question was in a state of evolution, and he believed that the medical profession should confine its efforts to establishing the principles under which insurance against medical costs could be established. According to Fishbein, the position taken by the House of Delegates was that the patient should receive a cash benefit based upon the cash premiums invested. The patient should e Bowman Crowell, Associate Director of the College, had been subpoenaed by the Federal Government to appear in court in Washington, D. C., to testify in a suit which the Government had brought against the American Medical Associa- tion. The Regents were concerned over the nature of the testimony which he might be asked to give, but it consisted of an identification of the report made in June 1934 by the Medical Service Board. It was this report which gained a great deal of newspaper publicity and drew the ire of the American Medical Association. 364 Fellowship of Surgeons have a free choice of his doctor, and the fee for the doctor's services should be a direct financial transaction between the doctor and the patient. In their desire to gain formal approval for actions which they had already initiated, MacEachern and Cutter repeated items on the agenda under different titles. They wished to co- ordinate the field activities of the two bodies and provide joint approval of schools for x-ray, clinical laboratory technicians and physical and occupational therapists. Regular conferences between the secretary of the Council on Medical Education and Hospitals and the Associate Director in charge of the hospital standardization program of the College were recommended. The representatives of the American Medical Association were concerned over the formation of the National Advisory Council on Medical Education, proposed by Willard C. Rappleye. Rappleye organized and held the first meeting of representatives of 12 national organizations on June 24, 1939. 7 The American Medical Association had disapproved of Rappleye's plan. As a result, the Council on Medical Education and Hos- pitals was not represented. Rappleye had been denied financial aid from the Federal Government but had received a grant from the Josiah Macy, Jr. Foundation. The principle had been enunciated that financial support should not be given by the medical organizations represented in the National Advisory Council. The commonly accepted and understood conception of the National Advisory Council on Medical Education was that it should act as a clearing house and advisory body on matters concerning medical education. Medical organizations should not handle matters of education in medicine. Medical education in

7 The organizations represented in the National Advisory Council on Medical Education were the Association of American Medical Colleges, American Hospital Association, Catholic Hospital Association, American Protestant Hospital Asso- ciation, Federation of State Medical Boards of the United States of America, Advisory Board for Medical Specialists, National Board of Medical Examiners, American College of Surgeons, American College of Physicians, Association of American Universities, American Public Health Association and Division of Medi- cal Sciences of the American Association for the Advancement of Science. Fellowship of Surgeons 365 all its aspects should be the prerogative of universities and colleges where medical educators trained in such matters should determine policies and set standards. Premedical education should be studied thoroughly as should the graduate years of the internship and residency. A license to practice medicine should be granted as a Federal function and should apply in all states of the union. This was reminiscent of Franklin Martin and within the Regents was supported vigorously by Howard Naffziger. Ob- viously, the American Medical Association saw in the Advisory Council a threat to the functions of the Council on Medical Education and Hospitals. The meeting ended with expressions of mutual admiration and respect. The Regents who attended were contagiously optimistic that future relations between the two organizations would run smoothly. They believed that they had delineated the lines of activities of the College to the satisfaction of the Trustees of the American Medical Association. Certainly, they demonstrated their compromising attitude under the guidance of Abell. A subsequent meeting between two Regents and two Trus- tees, with staff representation, occurred on February 7, 1940, to effect the mechanics of hospital registration and approval questionnaires outlined by MacEachern and Cutter. This was not a high-level decision for Regents and Trustees to be asked to make. Rapidly developing steps toward preparedness for a threatening war produced many obstacles to further formal conferences between the policy-malting bodies of the two organizations. Within a week after the meeting with the Trustees of the American Medical Association, the Regents met with representatives of the American Boards of Surgery, Ophthalmology, Obstetrics and Gynecology, Otolaryngology, Urology and Ortho- pedic Surgery. The discussion made it quite clear that all the groups were earnestly searching for the best methods of co- operation. No individual was present to point out that had Edward Martin's plan for reviewing application for Fellowship been successful or had Franklin Martin's plea that universities 366 Fellowship of Surgeons and colleges with medical schools assume the responsibility for the graduate education of surgeons, there would be no reason for the existence of the boards. The American College of Surgeons was experienced in the hospital standardization program. Therefore, it became understood, without the issuance of formal statements, that it would have to take over the activities of surveying institutions in which graduate training in surgery could be carried out. The need for additional approved residency training programs was expressed unanimously. The College could indicate what was necessary to establish such programs and stimulate good hospitals to improve by instituting a graduate teaching program. Teaching interns, residents and nurses, as well as encouraging research and investigation, would result in the best type of care for the patient. The Mayo brothers, Haggard of Nashville and other Regents who had served from the early days of the College had finished their terms, resigned or died. Younger men in surgery had taken their places. After several attempts, George Crile insisted that he be allowed to resign with the stipulation that his seat on the Board be given to Evarts Graham. Here was a man who had been influenced by his teacher, Arthur Dean Bevan, to distrust and be critical of every act and pronouncement of the American College of Surgeons. He had denied the right of the organization to elect him Vice- President without his permission and had faced the Regents with his criticisms. Nevertheless, on October 20, 1940, Graham took his place on the Board to serve for 13 years. Never did he consider himself too old to be elected to the Board of Regents or too old to be re-elected. France had declared war on Italy in June of 1940. The Japanese had invaded French Indo-China. The British army had miraculously escaped annihilation on the beach at Dunkirk only because of the mental quirks in the mind of Adolf Hitler. The bombing of Britain was to reach its tragic heights in December. Preparedness plans for military medicine went on. The Di- Fellowship of Surgeons 367 vision of Medical Sciences of the National Research Council created committees on surgery, medicine and information. In- numerable subcommittees and ad hoc groups were appointed to study and provide answers to a multitude of questions which could be applied to the solution of military medical problems. Again, there was a Council of National Defense which had a Committee on Health and Medicine under its direction. This time the American Medical Association assumed the leadership for the medical profession which it had failed to obtain in World War I. Under the chairmanship of Irvin Abell, the Regents listened to the verbose presentations from members of the administrative board. Approval of item after item on the program for each Clinical Congress occupied long tedious hours. It was a problem for the Regents to dissect the principles from the details presented, and it became more and more difficult to be sure they had come to the correct decision. Doctors who had entered the field of anesthesiology wished to become Fellows of the College. These men argued that they were closely associated with the surgeon in the treatment of his patients and were a necessary and integral part of the operating team. Some of the Regents argued that this was also true of radiologists and pathologists. Should doctors in each of these groups be considered as candidates for Fellowship? If so, what were the qualifications to be established? This initial attempt to enlarge the source material of candidates for Fellowship was frowned upon and placed in the category of subjects for future study. The Regents were attracted by a suggestion proposed by Owen Wangensteen, a young surgeon from Minneapolis. He recommended that a portion of the program at the Clinical Congress be devoted to the presentation of work done in experimental and clinical research by young men, even those still in their residency training. Wangensteen's idea was championed in the Board of Regents by Graham, and the first trial of the idea was made at a sectional meeting in Minneapolis in 1941. 368 Fellowship of Surgeons This program, known as the Surgical Forum, was very favorably received. Three sessions, each of three hours duration, were held at the Clinical Congress in Boston in November 1941. Thus, an innovation which required the co-operation of a doubtful administrative board, was a success from the beginning. It provided the only national meeting place where young aspiring surgeons could give expression to their scientific work. It seemed certain that with war approaching, the expenses of the College would be difficult to meet. Efforts to enlist the American Hospital Association and the American Medical As- sociation in sharing the operating expenses of the hospital standardization program were futile. The annual budget for this activity in which the Regents took justifiable pride, and which they would share only because of necessity, was $44,028. The United States became totally involved in war on Decem- ber 7, 1941, when the Japanese attacked Pearl Harbor. The Nazi-Soviet pact had been broken by Germany's attack upon the Soviet Union the preceding June. The alignment of allies was now established. The administrative board of the College procrastinated and argued the advisability of recommending that the Clinical Con- gress be canceled for the duration of the war. Finally, the Regents decided that the burdens placed upon the Fellows in every community and the terrific load on transportation facilities were too great to overcome in order to have successful Congresses. The Board members knew that it would be difficult to maintain the influence of the College among its Fellows without annual meetings. 8 The Regents continued their sessions but on a less frequent basis. Twenty-seven war session programs were held to aid in dis- seminating scientific knowledge specifically applicable to military medical problems. The motion picture library, which had been growing rapidly, was used extensively. The participation of the College in the graduate training of surgeons by the survey of institutions in which surgical resi-

8 The Clinical Congress was not held in 1942, 1943, 1944 and 1945. All of the officers and Regents were continued in office during these war years. Fellowship of Surgeons 369 dencies were, or could be established, continued. On May 5, 1944, Johnson & Johnson, a company which manufactured surgical supplies, donated $25,000 to the College to aid in carrying on this project. Within the year, a total of $132,160 was obtained for the graduate training program of the College. The committee had taken the position that for medical school graduates in 1944 and subsequent years, a minimum of two years of graduate training after an internship would be necessary in the surgical specialties. Three years of graduate training would be required in general surgery. The College's Committee on Cancer continued to work closely with the American Cancer Society, which until 1944 had been known as the American Society for the Control of Cancer. Congress authorized the President to proclaim a cancer control month, and the College announced that it had records of 29,195

"cured" cancer patients. There were 272 approved' cancer clinics throughout the country. Radio networks carried educational programs in which the National Cancer Institute, created by Congress in 1937, joined the American Cancer Society and the College in providing the public with factual information about the disease. A Gallup poll reported that 38 per cent of those questioned in a national survey knew one or more of its danger signals. The American Cancer Society made a grant of money to the College to finance the expense of surveying cancer detection clinics. Business leaders had joined the society and it was reorganized for a total national effort. A research program was instituted and, based upon a budget of 25 per cent of the amount of money raised, grants totaled $1,000,000. Within a year, 155 research grants and 42 fellowships had been established. A great deal had been accomplished in more than 30 years since the Clinical Congress of Surgeons of North America had sponsored the first public meeting on the subject of cancer. Doolittle's daring air bombing raid of Tokyo in April 1942 provided the only event of which Americans could boast in a thus far humiliating series of military operations. The Philip- 370 Fellowship of Surgeons pines had been lost. The United States found itself desperately fighting a war on two fronts, and arguments flew thick and fast as to which effort was the most important. Finally, a joint operation with the British occurred in North Africa. Successful naval battles were fought in the Pacific, and the invasion of France by the allied forces took place. The temporary setback in the Ardennes bulge, the Rhine crossing, Iwo Jima and Okinawa all followed in rapid succession. The German armies began to surrender on May 4, 1945, and an unconditional surrender was signed on May 7, 1945. Almost 10 years to the day after her husband's death, Isa- belle Hollister Martin died. The terms of Franklin Martin's will which conveyed all of the property and assets of The Surgical Publishing Company to the American College of Surgeons were in complete effect. Albert D. Ballou retired as General Manager of The Surgical Publishing Company. Through the efforts of his successor, James S. Shannon, improvements in the building and economies directed toward a more efficient management had placed the company in an excellent condition. At the persistent requests of Dallas Phemister, who had served as Secretary and Treasurer of the College, the Regents approved of a survey of the affairs of The Surgical Publishing Company by a company of business efficiency engineers. It was difficult for Phemister, influenced as he had been by Arthur Dean Bevan, to believe that Martin, Kanavel and their younger colleagues in surgery had not personally profited extravagantly from Martin's complete ownership of the publishing company. Mrs. Martin had insisted that these younger men continue to have their professional offices at the publishing company to comply with Franklin Martin's dictum that practicing surgeons were essential to the successful editing of a surgical journal. This tenancy was terminated within a week after Mrs. Martin's death. When Phemister inquired as to the men's future plans, he was pleased that their move had been voluntarily accomplished so promptly. The efficiency expert reported that the financial affairs of Fellowship of Surgeons 371 the publishing company were in order and that its business was being conducted efficiently. Following the survey, the company submitted its statement for $3,600. The Regents elected a Board of Directors for The Surgical Publishing Company. Shortly, the name would be changed to The Franklin H. Martin Memorial Foundation to comply with Mrs. Martin's wishes. The company would continue to publish Surgery, Gynecology 6- Obstetrics as a scientific surgical journal. Its editorial and business policies would be independent of the administration of the College, but its Board of Direc- tors would be representative of the Board of Regents. As a foundation organized not for profit, all earnings derived from publishing the journal would be donated to the American Col- lege of Surgeons. Such contributions would aid in supporting the College's projects aimed at continuing the surgical education of its Fellows and the elevation of the surgical treatment of patients. At the same time, the annual lecture in surgery at the Clinical Congress, which began as the Murphy Oration and then became the Oration in Surgery, was named the Martin Memorial Lecture. During the 10 years in which it had functioned, the Ameri- can Board of Surgery had gained in stature. The Board's certificate that the candidate had successfully passed its examination became the diploma of the young surgeon's training qualifications. Time alone had etched the differences in the sphere of activity between the Board and the College. The Board of Surgery could not exert any influence upon the surgeon after he had passed its examination. The College could discipline its Fellows' actions as surgeons and could vouch to the public for their professional and moral integrity. Evarts Graham, Frederick Coller and Arthur Allen represented the Regents in a conference with Fordyce St. John, Samuel Harvey and Stewart Rodman from the Board to study plans for closer co-operation between the American Board of Surgery, other boards of surgical specialists and the American College of Surgeons. The duplication of surveys for hospital standards and graduate surgical training programs was costly 372 Fellowship of Surgeons and confusing because often the lists of approval did not correspond. Such occurrences only served to magnify any reasonable differences between medical organizations into absurdities in the minds of the public. In March 1947, discussions between the College and the Council on Medical Education and Hospitals were begun. This was 10 years after the first approach had been made to the American Medical Association by the College. It had then been told that the Association was not interested in co-ordinating the efforts of the two organizations. Progress was slow. Through the years, just criticism had been expressed of the surgical clinics held in hospitals during the Clinical Congress. These had been the outstanding educational feature of the early years of the College. With the education and training of more competent and skilled surgeons, the need for watching a

"master surgeon" perform in order to learn had passed. The audiences were far too large to learn niceties in surgical technique. Surgeons had realized that it was more profitable to visit the surgeon at his daily work. The operating room was no place for a large group of visitors, improperly garbed, incor- rectly masked, milling about, conversing and crowding in upon the surgeon. The dangers of infection were unjustifiable. Johnson & Johnson had borne the expense of several motion pictures made under direction of Fellows of the College with the primary purpose of instruction by the use of animated drawings and other teaching devices. The College sent these films to sectional and chapter meetings and to medical schools. They were a popular innovation in surgical teaching. Individual Fellows made films which they sent to the College for approval and distribution. These motion pictures constituted far better teaching than the operative surgical clinic. With the advent of commercial television, it was natural that surgical procedures be televised from the operating room over a closed circuit to a meeting hall of the Clinical Congress. This was done successfully in 1947 at the Clinical Congress in New York City. With the advent of color television and the interest Fellowship of Surgeons 373 of the Davis & Ceck company9 in supporting the continued making of teaching motion picture films under the supervision of the College, the "wet" surgical clinic disappeared. It was evident that Fellowship in the American College of Surgeons must stand for more in the mind of the young surgeon than the certificate received from the American Board of Sur- gery. For many years, abortive attempts had been made to launch the junior candidate group successfully. The attractive- ness of the Surgical Forum program for young surgeons, the Cine Clinic, television, symposia and panel discussions by surgeons of repute and authority all contributed to the growth of interest in the College by young men in surgery. Other scientific programs were adopted for the Clinical Con- gress. A committee on the study of the nutrition of the surgical patient in relation to pre- and postoperative care was appointed. It was the investigative work of a pediatrician, followed vigorously by the interest of surgeons, which had resulted in such a rapid accumulation of knowledge regarding fluid and elec- trolyte metabolism in health and disease. The medical internists were openly doubtful that the unscholarly surgeon, who worked with his hands, should be concerned with such complicated physiological studies. This was a field of surgical education which would lend itself well to the course type of presentation by surgical teachers for those Fellows who wished to enroll for instruction during the Clinical Congress. The aim was to bring postgraduate courses of instruction in pre- and postoperative patient care to the Fellows. The administrative board continued to function laboriously. Malcolm MacEachern had been appointed Director of the Col- lege in October 1949, and Bowman Crowell retired as Associate Director on November 15, 1949. Arthur W. Allen became Chairman of the Board of Regents following the death of Irvin Abell on August 28, 1949. Born in

9 Later known as the Surgical Products Division, American Cyanamid Com- pany. 374 Fellowship of Surgeons Kentucky, Allen graduated in medicine from Johns Hopkins. He had successfully broken the barriers of resistance erected by native Bostonian surgical families to the outsider. He was charming, persistently but gently aggressive and had an inherent desire for and admiration of directness and efficiency. Naturally, it was quite impossible for Allen to travel back and forth between Boston and Chicago to direct the activities of the administrative board personally. Allen had been working quietly but effectively from the time he had been elected a Regent. He was aware of and sensitive to the actual neglect of the Board of Governors, that large house of representatives of the Fellows, in the affairs of the College. As Chairman of the Board of Regents, he quickly instituted the custom of inviting the chairman of the Board of Governors to attend all meetings of the Regents. He encouraged the chairman to report back to his Board and thus established a line of communication which had existed only by written memoranda. The Governors should nominate and elect the Regents and a committee from the Fellows should nominate and elect the officers of the College. In practice, a nominating committee had always been named by the Regents, but suggestions for new Regents or men to fill vacancies, created by resignations or death, accompanied the instructions to the committee. Realizing full well that the Board of Regents must have continuity of membership and consist of surgeons devoted to the future of the College, Allen began to correct the situation. He was also convinced, and was supported by the Regents, that the College needed a forceful Director with imagination and enthusiasm for the objectives of the College. MacEachern had devoted years of service and loyalty to the affairs of the American College of Surgeons. He had gained an international reputation as an expert on hospital standards, facilities and administration. In his prime, he had been all that Franklin Martin had claimed for him. As Director in his advancing years, he lacked decision, imagination and administrative ability and lost the confidence of the young surgeons on the Fellowship of Surgeons 375 Board of Regents. Led by Allen, the Regents sought and found a new Director in Paul R. Hawley, who was appointed on March 1, 1950. MacEachem was named Director Emeritus. The functions of the administrative board were ended. Frank- lin Martin had predicted that such an arrangement was faulty and should be continued only until a strong Director could be found, lest the activities of the College stagnate. His prediction had become only too evident. It had taken 15 years for the Regents to realize that Martin had not recommended any one of his staff as his successor. CHAPTER 12 AUL R. HAWLEY came to the American College of Surgeons Pas The Director with a distinguished record in the Medical Corps of the United States Army. Following graduation from medical school, he practiced with his father, a country physician, in the small Indiana town where he was born. The respect, affection and confidences which came to the family doctor from unselfish devotion to his patients in a small community were exemplified in his father. Trips to patients' homes in a carriage drawn by a team of horses, ankle-deep muddy roads which stalled his father's first automobile, deliveries of babies often unassisted except by the husband who administered the anesthetic, immediate and definitive surgical care for the seriously injured because there were no trained and qualified surgeons nearby were all experiences he had enjoyed with his father. With World War I imminent, Hawley passed the examination for the Medical Corps of the United States Army. Inherently a student, he later attended the Command and General Staff School, worked with Raymond Pearl in public health biostatis- tics, surveyed and effected revolutionary changes in disease prevention in Nicaragua and served in various routine posts in the Army. He became the medical member of the military task group sent to England early in 1941 before the United States entered World War II. Hawley became Chief Surgeon of the European Theater of Operations and served in this post throughout World War II. Under his direction, the treatment of the wounded, the administration of the Medical Corps in that theater and its co-operation with the high command and the allies were unsurpassed in that or any previous war. In 1946, Hawley became Chief Medical Director of the Vet- erans Administration when General Omar Bradley became the Fellowship of Surgeons 377 Administrator of that agency. It was Hawley's conception to obtain the association of medical schools with veterans' hospitals and place a part of the responsibility for elevating the medical care of veterans upon the shoulders of the medical school faculties. He was also responsible for removing medical professional personnel from the stifling, deteriorating influence of the civil service bureaucracy. Again, Hawley's sincerity and integrity won the full co-operation of suspicious medical school faculties, veterans' organizations, congressmen and the medical profession. Hawley resigned from the Veterans Administration with Brad- ley and became Chief Executive Officer of the Blue Cross and Blue Shield Commissions, voluntary insurance plans which were being formed locally throughout the country with doctors as participating organizers and directors. Each plan was autonomous but to be successful and combat the rising threat of governmental control of medicine, it was necessary to have a strong national leader who could persuasively influence the many state groups to act cohesively in formulating and effecting their plans. The Executive Officer had to speak and write convincingly, believe in the principle of voluntary health and hospitalization insurance plans, understand the proper ethical relations between patient and doctor and fight actively the threat of socialization in medicine. Arthur Allen, Chairman of the Board of Regents, was certain that Hawley was the man to become The Director of the American College of Surgeons. The College had grown to be comparable to a large industrial organization. It needed a Director who would be the executive officer of the Board of Regents; one who was directly responsible to them but who could and would make decisions in all matters upon which the Board had established a policy. The College needed a Director who would keep the Board of Regents fully informed of the affairs of the College, advise it upon actions which should be taken and recommend new areas in which the organization should exert its influence in medicine. Particularly, it was necessary to have a Director who 378 Fellowship of Surgeons could organize the administrative staff, supervise and direct their work, and yet avoid direct interference with the details of the work of his assistants. Allen and the other Regents were fully aware that the American College of Surgeons had lost prestige in the 15 years after Franklin Martin's death. The College needed a representative before other medical organizations and the public. A Director should not be restricted to uttering platitudes, or the reputation of the College would suffer. On the other hand, The Director should never make a public statement of which the Board of Regents would disapprove. In short, the Regents were demanding an agile literary and oratorical tightrope performer. They had learned that they must seek a Director who would have complete loyalty to the Board of Regents; one whose personal ambitions would not conflict with that loyal support. They did not want a "yes" man but one who would express his disagreement with the Board of Regents when, in his opinion, the contemplated action would not be to the best interests of the College. However, he would have to be the kind of man who would support the final decision faithfully and give to the utmost of his ability even though originally he might not have been in agreement. The Director would have to believe im- plicitly in the program of the American College of Surgeons and in the position taken by the Board of Regents in all matters of policy. Uncomplimentary remarks were made by Fellows of the Col- lege and members of the administrative staff about the "military mind" and Hawley's 30-year absence from the scene of civilian medicine and its problems. Despite these statements, the more the Regents looked at the qualifications of the candidate, the more convinced they became that Hawley was their unanimous choice. Hawley accepted the position because it presented the opportunity to associate closely with the medical profession, a desire which he had in part fulfilled during the war and as Chief Medical Director of the Veterans Administration. He had always thoroughly enjoyed his assignments in the Army Medical Fellowship of Surgeons 879 Corps when they provided him the opportunity to care for patients. He had learned the deep satisfaction which came from the patient's confidence in him. Hawley began his duties as The Director of the American College of Surgeons on March 1, 1950. His appointment was not greeted with unanimous approval. Some of the Fellows were distrustful of an ex-Army doctor. Many had been unable to adjust their civilian practices to military necessities and routines imposed by the chain of command. Opposition was expressed by some of the administrative staff who used the damnation by faint praise and innuendo technique to promote their own ambitions. It was, indeed, a difficult job to fill the shoes of Franklin Martin, whose human frailties and shortcomings were rapidly disappearing in the increasing aura of infallibility which had been created by his loyal adherents during the 15 years following his death. Hawley recognized the superb accomplishment of the Ameri- can College of Surgeons in attacking the problems of the improvement of the training of surgeons and the eradication of unethical practices. He was also aware of the restriction exerted by the College through indirection upon irresponsible surgery, since no legal restraint upon the practice of surgery by a licensed doctor existed in any state. The creation of standards for all phases of hospital operation, from protection against fire to the keeping of patients' medical records, and the many surveys of hospitals which voluntarily applied for recognition had cost the College about $2,000,000. The record was one of which it could be proud. In 1950, a total of 3,290 hospitals were on the approved list of the American College of Surgeons. There were other less favorable aspects of the results of the hospital standardization program. Its success had convinced the professional social planners that a hospital was a necessity in every small community in the United States. As a result, Con- gress enacted a law which provided a government subsidy which could be as large as 50 per cent of the cost of a hospital constructed by the citizens of a local community. 380 Fellowship of Surgeons Beautiful, well-equipped hospitals were springing up all over the rural United States. Unfortunately, too few properly trained surgeons were available to staff them. This was a consideration which had been forgotten by the theorists who believed that bricks and mortar made a hospital and that a graduate of a medical school could be equally skilled in all fields of medicine. Greatly improved methods of transportation could carry a patient to a medical center hundreds of miles away in less time than the doctor could have reached the patient's grandparent by horse and buggy over hub-deep muddy roads. This factor had been ignored completely. The result was that the general practitioner, untrained in surgery, was invited to perform surgery in a hospital with complete facilities only a stone's throw from his office. What was more difficult to combat was the fact that the courts in several states ruled that no licensed practitioner of the healing arts could be denied the use of a hospital supported by public funds. Hawley had faced a similar problem when congressmen insisted upon building Veterans Administration Hospitals in small communities in their districts but failed to realize the necessity for providing the services of qualified medical and surgical specialists. The American College of Surgeons had expended $68,577.27 on the hospital standardization program in the fiscal year 1949. The Regents were proud of the accomplishments of this project which the College had carried on from the beginning without help from other organizations and with a severe strain on its budget. Hawley was completely cognizant of the history of the hospital program, but it was apparent to a newcomer that other educational programs in which the College was interested also required financial support. Even with the previous year's expenditure of money, the hospital program had failed to meet the demands made upon it. Hawley suggested that the constant financial drain was of serious import to the College and that the question of supporting the hospital program should be studied seriously. Fellowship of Surgeons 381 Perhaps the time was right to inquire again as to the interests of other organizations on a co-operative basis. The new Director took the calculated risk of being accused that he was attempting to sabotage the College's great reputation by getting rid of the successful hospital standardization program. The American Hospital Association had become a strong organization. Its officers and many of its members believed that the time had arrived for them to assume the responsibility of hospital standardization. Quite justifiably, they believed that in their special field of hospital administration they could improve the standards. They recognized that the American College of Surgeons had achieved great success, particularly with regard to the professional aspects of the program. Hawley had gained the confidence of the Trustees of the American Hospital Association when he was Medical Director of the Veterans Administration and the Blue Cross and Blue Shield Commissions. In preliminary conversations, several of them assured him of their intention and ability to provide an initial annual budget of $100,000 for the hospital program. Trus- tee representatives of the hospital association made a proposal to the College of Surgeons indicating their desire to participate more actively and to assume the entire financial responsibility of the hospital standardization program. From the past record, there was no reason to believe that the American Medical Association would co-operate with the Col- lege and unify their programs. All the evidence was to the contrary. The Regents authorized their Chairman, Arthur Allen, to appoint a committee to meet with representatives from the Ameri- can Hospital Association to formulate a proposal for the transfer of the hospital standardization program of the College to the hospital association.' On July 21, 1950, the committees wrote the draft of an agreement for the transfer. They stipulated that if the transfer was to be effective, it should be made without I Frederick A. Coller, M.D., Warren H. Cole, M.D., and Paul R. Hawley, M.D., represented the American College of Surgeons. A. C. Bachmeyer, M.D., Frank R. Bradley, M.D., George Bugbee, John N. Hatfield and Joseph G. Norby represented the American Hospital Association. 382 Fellowship of Surgeons delay in order that the activities of the standardization program could continue without interruption. The proposal provided that the American Hospital Associa- tion should assume the budget for the personnel concerned with the College hospital standardization program. It was suggested that the Association negotiate directly with Malcolm Mac- Eachern for his services as Director of Professional Services, since he was retiring from the College. All of the pension rights of those employed in the program would be protected. It was agreed that the American Hospital Association would create a commission to consist of 25 members. Thirteen of these members, including the chairman of the commission, would be selected from individuals with outstanding records as hospital trustees. Six were to be hospital administrators, including the chairman of the Council on Professional Practice of the American Hospital Association. To fill the remaining places, the American College of Surgeons would appoint three surgeons and the American College of Physicians would select three physicians. These individuals, outstanding in their fields and all Fellows of the American Medical Association, would constitute a committee on medical and surgical standards and would have the right to appoint an advisory council representative of the American specialty boards. The hospital standardization commission would have final responsibility for the establishment of hospital standards for approval by the Trustees of the American Hospital Association. Only those hospitals recommended could be granted approval. The Board of Trustees of the American Hospital Association had somewhat prematurely issued a public statement that it intended to own and operate its own program of hospital standardization. Hospital administrators were convinced that not enough attention was being paid to accounting methods, heating, maintenance problems and other services which hospitals had in common with hotel management. The Association did not intend to interfere with professional standards, they stated, but saw no reason why the two areas of hospital service Fellowship of Surgeons 383 to the patient could not be kept at high levels by a co-operative effort. These were only preliminary suggestions. The conferees had agreed to make a joint announcement if and when plans were completed. This first proposal was rejected by the Board of Regents on August 4, 1950. In spite of these facts, rumors and charges were prevalent that the American College of Surgeons was abandoning the hospital standardization program completely. What was more despicable, it was said, was that the project was to be turned over to laymen who would now set the standards for hospitals and the professional care of the patient. The American Academy of General Practice, it was strongly suspected, had succeeded in having the House of Delegates of the American Medical Association adopt a resolution to the effect that the American College of Surgeons had no business in the field of hospital standardization. After a heated debate in a reference committee, the House of Delegates finally rescinded the motion. Immediately, however, the Trustees of the American Medical Association demanded that since it represented all doctors, they should be included in any conference which would disturb the status quo of the hospital approval activities of their Council on Medical Education and Hospitals or the American College of Surgeons. They said they had been ignored and would oppose any plan which the American Hospital Association dominated. Representatives of the American Medical Association even proposed that they would share the financial burden of the College and co-operate to the fullest extent in the administrative responsibilities of inspection and approval. 2

2 Drs. Elmer L. Henderson and Gunnar Gundersen, Trustees of the American Medical Association, appeared before the Board of Regents in Boston, Massa- chusetts, on October 22, 1950. On September 30, 1950, representatives of the American College of Surgeons, American Medical Association, American Hospital Association and American College of Physicians had met in Chicago to discuss a co-operative hospital standardization program. Subsequent meetings of the same groups were held on October 8, 1950 in Washington, D. C., and on November 19, 1950, and March 4, 1951, at the American College of Surgeons headquarters in Chicago. See Appendix, Chapter 12:1 for the names of the representatives of each organization. 384 Fellowship of Surgeons At long last the American Medical Association had admitted the pioneer efforts and the success of the hospital program initiated by the College. The Association was anxious to unite with the College against hospital administrators and trustees whom it considered a common enemy. The Governors and many Fellows of the College of Surgeons were disturbed over the spreading rumors which contained fewer and fewer facts with each telling. At a meeting in Boston, the Governors expressed the hope that voluntary contributions from Fellows and from other sources would solve the financial problem imposed on the College by the hospital standardization program. They desired the College to continue to support and control the program singlehandedly. An opportunity was given to 8,000 Fellows, whose dues had been paid in full, to contribute to a special fund for this purpose. In six months, 624 Fellows contributed $19,782, a response which did not augur success. Despite this poor response, representatives of the College indicated rather forcibly that they could continue to finance the program. They believed it might be wiser to break off all discussions, since the American Hospital Association and the American Medical Association had created a stalemate by their uncompromising attitudes. The hospital association wished to co-operate with the College of Surgeons but not with the medical association; the medical association would not accept a program dominated by the hospital association. The stenographic reports of the several conferences are highlighted by tangential discussions, misstatements of facts, misunderstandings of purposes and evasive answers to pointed questions. They show illogical presentation of organizational policy, jealousies, charges of unfair and prejudicial editorial statements in the Journal of the American Medical Association and repetitious statements that the American Medical Associa- tion, the only organization representing all doctors, was ignored in the original discussions. Arthur Allen, however, was always able to point out enough encouraging progress to obtain agreement for another meeting. Fellowship of Surgeons 385 Eventually, Evarts Graham summarized the situation by stating three possible solutions. The American College of Surgeons could continue its highly successful program of hospital standardization and secure financial assistance on its own initiative or accept that offered by the American Medical Association. Graham assumed that the representatives of the latter association were speaking with the approval of their House of Dele- gates and was assured that they had been so instructed. The second plan would be financed and administered by the American Hospital Association with the professional standards aspect of the program controlled completely by the medical organizations. Since the American Medical Association was adamantly opposed to this plan, there seemed to be no purpose in discussing it further. Graham proposed, therefore, that an independent commission be established which would be financed jointly by contributions from each participating organization. The commission would be representative of each group but would administer its own affairs independently. Members of the commission would be the participating organizations, each of which would be represented by appointees of its choice. The Canadian Med- ical Association should be invited to become a member, although the American College of Surgeons, the American College of Physicians and the American Hospital Association included Canadian members. It was agreed that the medical profession of Canada, as a whole, might desire representation similar to that furnished by the American Medical Association. This proposal was not found completely objectionable, but its consideration was clouded by discussions upon the functions of each parent member organization. Should they continue to carry on their existing inspections for approval? Some claimed that the American Hospital Association would then insist upon inspecting hospitals from the standpoint of its particular interests. Should the commission include educational standards in its approval? How could any approved hospital not be considered a teaching institution? The functions of the Council on Medical Education and Hospitals in approving intern training programs 386 Fellowship of Surgeons would be compromised as would the graduate training program of the College of Surgeons. Fred W. Rankin, representing the College of Surgeons, finally proposed that a subcommittee be appointed to work out a plan of representation on a joint commission, the exact name of which could be decided later. He argued that if the conferring groups could agree on fair representation on the commission, other problems could be resolved quickly. Paul Hawley, George Lull, George Bugbee and LeRoy Sloan, representing the American College of Surgeons, the American Medical Association, the American Hospital Association and the American College of Physicians, respectively, submitted the plan which was eventually adopted. It was proposed that the American Medical Association and the American Hospital Association have six representatives. The American College of Surgeons and the American College of Physicians would have three each. The Canadian Medical Association and the hospitals of Canada, if they wished to join, would each be entitled to one representative. The commission would formulate standards, determine the type and scope of inspections, allocate hospitals to the several participating organizations for inspection, maintain all records and award all certificates of accreditation. Inspections would be made by the field staffs of the participating organizations and could be combined with other inspections made by them for other purposes, such as approval of programs for intern and resident training. All inspections for accreditation were to be made and reported in a uniform way to the commission. The staff of the commission would evaluate the reports, and final action would be taken by the commission. Member organizations would contribute funds in the same proportion as their representation. The annual budget was estimated at $70,000, exclusive of the expense of the field inspections which would be met by the American College of Surgeons and the American Medical Association, the only organizations which had field staffs. The Regents of the two Colleges quickly approved the proposal. The House of Delegates of the American Medical Asso- Fellowship of Surgeons 387 ciation instructed its representatives to make an effort to obtain eight representatives and reduce those of the American Hospital Association from six to four. However, it did give its conferees power to act. After warmly defending their position, they finally acquiesced to the majority opinion. The House of Delegates of the American Medical Association approved the proposal on September 16, 1951. On March 8 and 9, 1952, the Joint Commission on Accredi- tation of Hospitals was formally organized in Chicago. Edwin L. Crosby, a doctor, was elected Director. Crosby had been director of the Johns Hopkins Hospital in Baltimore and was president - elect of the American Hospital Association. It was agreed that headquarters for the Commission would be established in the property of the College of Surgeons at 660 Rush Street, Chicago, and that a fair rental fee would be sub- tracted from the contribution of the College to the annual budget of the Commission. The formal transfer of the hospital standardization program of the College took place on December 6, 1952. The problems of transition were somewhat alleviated by the fact that the Commission agreed to accept as its initial list the roster of approved hospitals furnished by the American College of Sur- geons.3

3 A gentlemen's agreement provided that the chairmanship of the joint Com- mission would be rotated among the participating organizations. The first chairman was Gunnar Gundersen, La Crosse, Wisconsin, representing the American Medical Association. The composition of the first Commission was: American College of Physicians: Alexander M. Burgess, Providence, Rhode Island; William S. Middleton, Madison, Wisconsin; and LeRoy H. Sloan, Chicago, Illinois. American College of Surgeons: Arthur W. Allen, Boston, Massachusetts; Evarts A. Graham, St. Louis, Missouri; and Newell W. Philpott, Montreal, Quebec. American Hospital Association: Edwin L. Crosby, Baltimore, Maryland; Judge Milton George, Morden, Manitoba; John H. Hatfield, Philadelphia, Pennsylvania; Rt. Rev. Monsignor John J. Healy, Little Rock, Arkansas; Stuart K. Hummel, Joliet, Illinois; A. J. J. Rourke, San Francisco, California; and Charles F. Wilinsky, Boston, Massachusetts. American Medical Association: Gunnar Gundersen, La Crosse, Wisconsin; L. W. Larson, Bismarck, North Dakota; Julian P. Price, Florence, South Carolina; Stan- ley A. Truman, Oakland, California; Herman G. Weiskotten, Skaneateles, New York; and Rolland J. Whitacre, East Cleveland, Ohio. Canadian Medical Association: E. K. Lyon, Leamington, Ontario; and A. D. Kelly, Toronto, Ontario (Alternate). 388 Fellowship of Surgeons In the preceding 35 years, the hospital standardization program had become a powerful factor in elevating the standards of surgical treatment. The logical extension of the functions of the hospital was recognized. It was no longer merely a place for the sick to be treated and was serving in many communities as the center from which all health activities radiated. The hospital had become the most important and most expensive factor in medical education. Present-day medical schools cannot exist without teaching hospitals. The education of nurses and laboratory technicians cannot be carried out without their assistance. The first inspection of hospitals in 1918, under the program initiated by the College of Surgeons, revealed that only 89 hospitals of 100 beds or over out of a total of 692 were able to meet even the barest interpretation of the minimum standard established. In the final list turned over to the Joint Commission, 3,352 of 4,111 hospitals of 25 beds and over in the United States, Canada and other countries were able to meet the maximum interpretation of the minimum standard. Just as when the American College of Surgeons began its hospital program, so did the Joint Commission encounter criticisms and resistance. This opposition came mainly from doctors who insisted that it was interfering with their licensed rights to practice medicine. Other organizations, particularly the American Academy of Obstetrics and Gynecology and the American Academy of Gen- eral Practice, began to seek a participating membership on the Commission. They did so because they believed that the Com- mission did not understand the problems of practice peculiar to their members. They also felt that hospital governing boards and medical staffs discriminated against the rights of their members to practice in any specialized field of surgery or medicine of their own choice, regardless of the best interests of the patient. In an effort to placate the Academy of General Practice which was rapidly gaining strength within the House of Delegates, the American Medical Association agreed that general practitioners would be among its representatives. Thus far, members of the Joint Commission, with integrity and the dedicated de- Fellowship of Surgeons 389 sire to keep the levels of medical practice high, have maintained the ideals and procedures of the Commission on a su- perior plane. Hawley's early days as The Director of the American College of Surgeons were concerned with another problem which had beset the Regents for many years. It did not have such important overtones to the financial condition of the College as the unification of the hospital standardization program which Ar- thur Allen and he had so patiently worked to accomplish. However, it was of more importance to the education and training of future surgeons. A surgical specialty board in ophthalmology had been established in 1917 and one in otolaryngology by 1924. However, it was not until the American Board of Surgery came into existence in 1937 that the College of Surgeons concerned itself actively in the evaluation of the institutions at which training in general surgery could be obtained. Through the existing mechanism of the hospital standardization program, the College then quickly investigated and approved residency training programs. It had raised its own standards for candidates seeking Fellow- ship by requiring a minimum of two years of residency training. Later, this had been increased to three years. Attempts had been made to correlate the work of the Council on Medical Education and Hospitals with that of the Graduate Training Department of the College. Meetings were held but little had been accomplished. Training programs were approved by both organizations, and often they were in disagreement. Men returning from service in the armed forces were clamor- ing for programs of formal graduate training in surgery. They were confused by the lack of agreement on approved programs. The desire of these men to receive training in surgery in an approved residency was heightened by the apparent prefer- ential recognition which certain governmental medical services gave diplomates of the various surgical specialty boards over Fellows of the American College of Surgeons. The government services offered higher pay to specialty board diplomates in an effort to stimulate their medical officers 390 Fellowship of Surgeons to become better trained. The boards covered the specialty fields in both medicine and surgery and avoided the necessity for the government services to recognize individual professional organizations. Hawley had been at work only less than a month when he learned that unless vigorous action was taken quickly, the graduate training program of the College might be sacrificed. The staff representatives of the College were obviously no match for their opposite numbers from the Council on Medical Edu- cation and Hospitals. The Director immediately sought an interview with War- field Firor, chairman of the American Board of Surgery, and visited him in Baltimore. He explained the background of the efforts of the College to elevate the standards in graduate training in surgery. He emphasized that the stakes of the Board and the College in the graduate training program were similar. Firor was educated in the Johns Hopkins Hospital residency training program in surgery. He was not a Fellow of the Col- lege and in many respects he was not acquainted with all the facts presented by Hawley. He was, however, deeply concerned about raising the standards of residency training in surgery. At Firor's suggestion, Frederick Coller, chairman of the Committee on Graduate Training in Surgery of the College, Hawley and he met and discussed the problems in which their two organizations had a mutual goal. It was not difficult for them to reach agreement. As a series of meetings was held between representatives of the College, the Council on Medical Education and Hospitals, the American Board of Surgery and other surgical specialty boards, it became apparent that a lack of information existed concerning the activities of each group and a more serious de- ficiency in communication. The Council on Medical Education and Hospitals approved institutions which offered short-term residencies. Warfield Firor, representing the American Board of Surgery, believed that such short surgical residencies should not be recognized by the Board. Other representatives of the Board, including Samuel Harvey, who had been the first chairman of the graduate training corn- Fellowship of Surgeons 391 mittee of the College, expressed great surprise when they learned that the College did not consider for approval graduate training programs of less than three years of progressive experience. As knowledge of the extent and thoroughness of the graduate training surveys conducted by the American College of Surgeons was gained, many of the objections were overcome. The American Board of Surgery was in no position to conduct its own surveys of surgical residency training programs. Yet, members of the Board had not investigated the survey program of the College. Rather, they assumed that College approval of graduate training programs in surgery was based on the general information obtained only through the hospital standardization survey. The College representatives insisted upon maintaining their own standards concerning graduate training programs and publishing their list of approved programs. They wished to continue to advise and help trainees to find residencies and aid in the establishment of proper educational training in surgery in suitable institutions. These were functions performed by no other organization. Relations between the American College of Surgeons and the several specialty boards continued to improve. The objective seemed clear and simple. Uniform standards of survey for approval of graduate training programs should be established and agreed upon by all organizations seeking the elevation of the standards of training in medicine and surgery. A resolution had been passed by a subcommittee on professional standards consisting of representatives of the Ameri- can Medical Association, the American College of Surgeons and the specialty boards. This resolution proposed that requirements for the length and character of training programs in surgery be formulated by these groups, with the specialty boards in a consulting capacity to the actual work to be carried on by the College and the American Medical Association.* However, no further action had occurred. Delay in effecting such a co-ordinated effort appeared to ° See Appendix, Chapter 12:2. 392 Fellowship of Surgeons come from the administrative staff of the Council on Medical Education and Hospitals. Finally, in May 1949, Donald G. Anderson of the Council proposed what he termed an "informal trial period" of several months or a year. During this time the administrative staffs of the College and the Council would co- ordinate the survey schedules of their field representatives to avoid overlapping or duplication. The reports of these surveys would be made available to both organizations. Periodical meetings could be held to discuss the rating of institutions for graduate training about which there might be differences of opinion. Anderson emphasized the wide differences in standards which existed and the differences in fields of major interest of the two organizations. He implied that the standards of the College were lower than those of the Council. The facts were quite different. However, the tactical advantage rested with the late corner to the field of endeavor which usurped the experience gained through hard labor by the pioneer and then adopted an air of superiority. Delays and obstacles arose because committees and subcommittees were attempting to solve the problems of residency training in general surgery and each of the surgical specialties at the same time. Numerous meetings were held, but nothing accomplished with certainty until it was agreed that the problems involved in a common standard for graduate training would be simplified if the effort in the beginning was confined to general surgery only. On April 15, 1950, an agreement wt,s reached by the representatives of the American Board of Surgery, the American Col- lege of Surgeons and the Council on Medical Education and Hospitals of the American Medical Association. It was ratified by the three organizations within the following two months. The agreement provided for the joint approval of residencies for training. A single survey service for the three bodies would be administered by the Council on Medical Education and Hospitals. The appraisal of the professional staff in charge of each residency program would be delegated to a committee made up of representatives of the American College of Surgeons Fellowship of Surgeons 393 and the American Board of Surgery. The survey data and the evaluation of professional personnel would then be submitted to a joint committee of the three bodies and a single approved list issued. The cost of the services would be prorated among the three groups, and the joint relationship would be announced publicly and stated specifically to the hospitals to be surveyed. Other specialty boards were to be invited to enter into a similar arrangement with the Council and the College of Surgeons. On May 25, 1950, the Conference Committee on Graduate Training in Surgery was organized.' It functioned smoothly and with good results, although there were wasted hours spent on discussion of details such as the mailing address and stationery designs raised by administrative staff members. Quickly, preliminary meetings were held with several of the specialty boards, but initial enthusiasm began to wane. There was evidence that the Council on Medical Education and Hos- pitals, stimulated by its secretary, Edward Leveroos, did not wish to have the organization approved for general surgery repeated in the surgical specialties. The Council on Medical Education and Hospitals was not represented on the professional standards subcommittee. The Council had insisted upon having one member of its administrative staff on the Conference Committee in contradistinction to the two other organizations which were represented wholly by surgeons. The administrative staff of the Council made several proposals for a change after the formation of the Confer- ence Committee, which was termed unwieldy and inefficient. At the same time, bilateral agreements were being made between the representatives of several of the surgical specialty boards and the Council on Medical Education and Hospitals to use as evidence that the participation of the American College of Surgeons was quite unnecessary. In spite of the bickering,

4 The first Conference Committee on Graduate Training in Surgery consisted of Warfield M. Firor, William D. Andrus and Peter Heinbecker representing the American Board of Surgery; Frederick A. Caller, Alfred L. Blalock and Warren H. Cole from the American College of Surgeons. Harvey B. Stone, Guy A. Cald- well and Edward H. Leveroos represented the Council on Medical Education and Hospitals of the American Medical Association. 394 Fellowship of Surgeons however, a similar conference committee in the field of otolaryngology was formed. It became necessary for a negotiating committee to attempt to settle the objections raised by the Council on Medical Edu- cation and Hospitals which, if met, would guarantee the Coun- cil's predominance in the graduate training programs. The American Board of Surgery and the American College of Sur- geons agreed to eliminate the professional standards subcommittee and, consequently, to have only one secretary. They insisted that at least two of the three representatives from each parent group be a general surgeon. The American Medical As- sociation would bear the expense of surveys and secretarial service. The other two organizations would divide equally the expense of evaluating the training programs. The Conference Committee was quite opposed to the suggestion made by a College conferee that it elect its own chairman, vice-chairman and secretary periodically without any binding qualifications as to which organization each officer represented. Instead, the representatives of the Council on Medical Education and Hospitals proposed that the chairman and vice- chairman be representatives of the College of Surgeons or the Board, providing that both positions should not be filled by men from the same organization at any one time. There was the added proviso that the secretary, however, would always come from the Council. Since it was recognized that the secretary would actually do the work and represent the Conference Committee, this was regarded as essential to insure the Council's predominant position in the program. The counter proposal would establish an independent secretary in an office unidentified with any of the organizations. The Regents of the American College of Surgeons had as their objective the elevation of the standards for graduate training in surgery and the surgical specialties. They believed that this transcended allocation of credit or priority. The members of the American Board of Surgery supported the Regents in this position, and both groups approved the plan of organization proposed by the Council on Medical Education Fellowship of Surgeons 395 and Hospitals. Separate stationery with the names of the component bodies and officers was to be used, and letters of approval of training programs to hospitals would be signed by the chairman of the Conference Committee on Graduate Training in Surgery. On September 1, 1953, the first list of residency training programs in general surgery and the surgical specialties approved by the Conference Committee was published. It included civilian hospitals in the United States and Canada and United States Government hospitals.

Another problem of policy came to the attention of the Regents at the Boston meeting in 1950. A critical shortage of anesthetists existed in the military hospitals during World War II. Many medical officers, without adequate training, were given the duty of establishing a section of anesthesiology in the hospitals. Trained anesthesiologists in the armed services worked assiduously to recruit candidates to enter this specialty field through a formal residency training program which would qualify them for the examination of the American Board of Anesthesiology. Anesthesiologists, with but a few outstanding exceptions, were forcefully advancing the principle that they should have the same relation with patients as other doctors. This was not a debatable issue. However, the leaders of this movement went a step further and stated that an anesthesiologist should not receive remuneration from a hospital or medical school for his service to patients and for his teaching duties. They held that anesthesiologists should practice only on a fee-for-service basis with submission of their bill directly to the patient. By having an interlocking board of directors between the American Board of Anesthesiology and the American Society of Anesthesiologists, it was not difficult to discipline and punish those anesthesiologists who believed it their right to practice their specialty and receive remuneration for their services as they pleased, as long as they practiced in an ethical manner. The anesthesiologists believed that since they were intimately 396 Fellowship of Surgeons associated with the surgeon in the operating room, they should be recognized on an equal footing. In fact, they advanced the view that they should be in sole charge of all fluids, drugs and resuscitative measures administered to the patient preopera- tively, during the operation and postoperatively. Many surgeons strengthened this position because they wished to divorce themselves from the additional distractions and responsibilities of the patient's anesthetic during the operation. Other surgeons strongly opposed such an independent position particularly since the patient's life was their responsibility. They recognized the value and importance of the well-trained anesthesiologist. They wished to establish a completely co-operative and consultative relation between surgeon and anesthesiologist but insisted that the surgeon bear the primary responsibility for his patient. Harold Foss, a Regent from Danville, Pennsylvania, was the chairman of a committee which studied the problem since suggestions had been made that anesthesiologists be admitted to Fellowship, or associate Fellowship, in the American College of Surgeons. Foss' committee was assisted by Henry K. Beecher, an outstanding anesthesiologist. Beecher believed that his specialty had to develop from within itself and would only suffer in stature by legislative measures designed to gain rapid maturity and dignity. Many Regents and Fellows were strongly opposed to offering Fellowship or associate membership in the College. It was the recommendation of the committee that a close liaison be established between the College and the anesthesiologists. If not feasible to admit them to full Fellowship, then a plan of associate Fellowship should be worked out by the central office and submitted to the Regents at a subsequent meeting for further consideration. No action was taken by the Regents, and the committee was disbanded on April 14, 1952. It was debatable whether or not this was the procedure by which the College of Surgeons could help the anesthesiologists establish their specialty on a high plane. Henry Beecher had stated that of approximately 3,000 anesthesiologists in the country, only 700 held the certificate of the American Board of Fellowship of Surgeons 397 Anesthesiology. Of the latter, it was his opinion that not more than 100 would be interested in Fellowship in the American College of Surgeons. The problem, therefore, concerned the trade-union tactics of the majority of anesthesiologists who intended to force their ideas and beliefs upon the young, rapidly growing specialty. In 1953, a well-trained, reputable anesthesiologist related to the Board of Regents the labor goon tactics which had been used against him and his family by his fellow anesthesiologists because he directed the department of anesthesiology in a hospital, taught residents in training, trained nurse anesthetists and received his remuneration from the hospital . 5 Again the Regents attempted to help relieve the growing pains of the new specialty. Another committee was appointed. Through the efforts of its chairman, I. S. Ravdin of Philadelphia, who met alone with representatives of the American Board of Anesthesiology, the interlocking relationship of the governing bodies of the two groups was weakened. It became slightly more difficult for the certificate of the American Board of Anesthesiology to be taken away from the individual who practiced ethically but did not conform to the economic dictates of the American Society of Anesthesiology. Still later, a third committee of the Regents attempted to establish qualifications for the admission of anesthesiologists into Fellowship of the College in the hope that the professional and ethical practices of these specialists might be elevated. This committee failed to make recommendations which were acceptable to the Board of Regents. In the meantime, the passage of years has tempered a revolutionary urge to gain quick su- premacy into an evolutionary movement of progression, which more certainly gains the respect and dignity due an important special field of medicine. Arthur Allen was convinced that while the Board of Regents was responsible for establishing the policies of the American

5 Dr. Lloyd H. Mousel of Seattle, Washington, appeared before the Board of Regents in Los Angeles, California, on April 4-5, 1953. 398 Fellowship of Surgeons College of Surgeons, the Board of Governors had never been consulted as a body in the affairs of the College. He asked William L. Estes, Jr., chairman of a committee from the Board of Governors, to appear before the Regents and present suggestions for closer co-operation between the two groups. Estes was an ideal choice to lead the Governors during this period. He was a well-trained surgeon completely familiar with the problems of practice in smaller communities. He was active in the communal affairs of his city and in his state medical society. Estes recognized the importance of placing the responsibility for the College in the hands of a small body of men. His open personality and integrity won the confidence of the Gover- nors. They were quite sure he would not sacrifice this trust for a personal gain. The Governors believed they could be of help in the organization and formation of local chapters of the Fellows of the College, the first of which had been established in Brooklyn. They wished the Board of Regents to define more in detail the duties of the Governors and their place in the organization of the College. Allen appointed a committee, which recommended that the Board of Governors elect its own officers and that three of its members be invited to attend each meeting of the Board of Regents. The committee further suggested that the Governors be encourged to reach the grass-root level of the Fellowship, that they be given the duty of investigating various problems in their areas and, finally, that the bylaws of the College with respect to the Governors be reviewed critically.° Many generalizations concerning the duties and responsibilities of the Governors had been made in the past. There the matter had always ended. Allen and Estes wished to spell out certain activities in detail. The Governors could not interpret policies of the Board of Regents to the Fellows unless they were apprised of the actions taken. Many problems which came to The Committee was composed of Henry W. Cave, New York City, chairman; William L. Estes, Jr., Bethlehem, Pennsylvania; I. Mims Gage, New Orleans, Louisiana; James M. Mason, Birmingham, Alabama; and Gilbert J. Thomas, Bev- erly Hills, California. Fellowship of Surgeons 399 the Regents could be referred to the Governors. Allen immediately initiated the custom of inviting the Chairman of the Board of Governors to attend all meetings of the Regents. Governors could be ex-officio members of their respective credentials committees and should be consulted when appointments were made to these committees and to the committees on applicants. The formation of local chapters of Fellows, the junior candidate group, judiciary disciplinary problems and sectional meetings were activities in which the Governors could play a responsible role. These were only the initial skirmishes which preceded the real issues at stake. With good reason, but without complete understanding of why it had occurred, belief existed among the Fellows that the Board of Regents was a self-perpetuating body. It was charged that the majority of Regents were professors of surgery who were not in touch with the practitioners of surgery in the large number of towns and cities of the United States and Canada in which there were no medical schools. Also, it was claimed that the Regents chose the officers of the College through the simple mechanism of having the President appoint the nominating committee. The question of the interest in the College of men trained in the several surgical specialties was raised by Charles C. Higgins, a Governor from Cleveland. Only about 25 per cent of the specialists in surgery were Fellows of the American College of Surgeons. Higgins found, as a result of questionnaires he sent out, that they rarely attended the Clinical Congress. They were dissatisfied with the programs offered and believed that men in specialty groups had rarely held any office of importance in the College. In fact, they believed they were the "unwanted stepchildren" of the College. Willard H. Parsons of Vicksburg, Mississippi, succeeded Estes as Chairman of the Board of Governors. Attending meetings of the Regents religiously, he stated that he soon realized the number of intricate problems presented to the Regents for solution. He appreciated the time and effort which they gave to the College. By insisting that the Governors conscientiously 400 Fellowship of Surgeons and consistently discharge the duties referred to them, Parsons and his executive committee gradually built up the participation of the Governors in the affairs of the organization. They also persistently pressed for more responsibility in the election of officers and Regents. The Governors proposed that their Chairman appoint a committee of three to act with a similar committee from the Regents to make recommendations concerning the method of electing officers of the College. They were convinced that the procedure in use was undemocratic and unsound. The terms of service of the Regents was a problem which had faced the College from its beginning. It was difficult for the Regents to imagine replacing a loyal, interested and dependable member of their group with an untried, younger man who had been critical of the College and whom they thought might be a revolutionary. Some of them pointed out that when rebellious liberals had been elected Regents, they had then become the most conservative and reactionary members. The Governors proposed that the term of Regents be limited to three years and that no more than three terms be served. They did suggest strongly that an exception be made in the case of the Chairman of the Board of Regents. Allen was em- phatic that no exception should be made in the case of a Chairman, who was elected annually as their presiding officer by the Regents, and that he should enjoy no special privilege. Allen maintained that four terms of three years each for Regents would be more advantageous to the College. It did take some time for a Regent to acquaint himself with the affairs of the College and, therefore, become more helpful. Progressively, more problems were referred to the Board of Governors. The vexatious question of surgeons traveling to other communities, operating upon a patient and leaving the postoperative care entirely in the hands of the local doctor was studied by the Governors. Itinerant surgery was necessary in the years of few and poorly equipped hospitals and inadequate transportation facilities, but that era had passed. The Governors' committee had the impression that the question of the improper division of fees was involved in the practice. Fellowship of Surgeons 401 The problems which had arisen in the relationship between surgeons and anesthesiologists, the suggestion that special sections in the surgical specialties be created within the College and methods to interest surgical residents in the voluntary disciplines in surgical practice imposed by the College occupied the attention of the Governors in the final years of Arthur Allen's chairmanship of the Board of Regents. Finally, changes in the bylaws were worked out by co- operation and with the guidance of The Director. These changes gave the Chairman of the Board of Governors, in consultation with his executive committee, the responsibility for appointing a nominating committee to proposed candidates for election as Regents. An advisory committee appointed by the chairman of the Board of Regents would consult with the Governors' committee. Similarly, the President of the College would select a nominating committee, which would advise with the same advisory committee from the Regents, to choose candidates for the officers of the College. It immediately became the custom for the Chairman of the Board of Regents to name past Presi- dents of the College, who were made members of the Advisory Council upon the completion of their term, to the committee to advise upon nominations. Their advice should be unprejudiced and impersonal. It had taken a long time to weld the elements of the College together by a common bond. It was fortunate that such steps had been initiated by Allen and the new Director. The College was entering a phase of its existence when its influence with the profession and the public was to reach its highest point. This was not to be accomplished without travail. Allen's successor as Chairman of the Board and Paul Hawley, The Director, were to be subjected to personal criticism. The laborious efforts of the American College of Surgeons to build a surgical organization, founded on voluntary discipline of its Fellows in the art and practice of their surgical skill and which had elevated the standards of surgery, were to be en- dangered by the dangling of memberships in another surgical group before doctors in the general practice of medicine, who had expressed an interest in surgery, but who for various 402 Fellowship of Surgeons reasons had not made the sacrifices necessary to receive the years of graduate training in surgery which the American Col- lege of Surgeons demanded of its applicants. Together with this attempt to recognize lower standards of surgical training, fee-splitting, unnecessary surgical operations, ghost surgery and exorbitant fees appeared cyclically on the horizon of surgery. They would demand a renewed vigor in the battle which the American College of Surgeons had always made against them. CHAPTER 13 VARTS A. GRAHAM became a member of the Board of He- t gents in 1940 to fill the vacancy created by the resignation of George W. Crile. He was elected Chairman of the Board on November 9, 1951, and had nearly completed the 12-year tenure which Arthur Allen had initiated and the Regents and Governors had agreed would be a matter of future custom. Bluntly outspoken, previously highly critical of the College, Graham had become the most ardent, uncompromising champion of the organization which alone had been the pioneer in elevating the standards of surgical care of patients. Graham bad left Chicago after having spent a semiformal period of surgical training at Presbyterian Hospital under the teaching of Arthur Dean Bevan. He chose to begin his practice in Mason City, Iowa, and resolved to limit himself to the practice of surgery. He was warned that this would be impossible. His sojourn in Mason City was not long. Quickly, he found that he had to choose between operating upon patients and splitting the surgical fee with the referring physician, practicing in every field of medicine, or starving. Graham continued to practice surgery and attempted to conduct a one-man campaign against fee-splitting. He enlisted the aid of newspaper editors and furnished them with the details of the patients' illnesses and the economic and moral principles involved in the division of fees. He made it plain that patients were for sale in Mason City. However, the first World War intervened and the impasse between him and the medical profession of Iowa was resolved. Upon returning to civilian life, Graham accepted the Bixby professorship of surgery and chairmanship of the department at Washington University Medical School in St. Louis. This was one of the first chairs of surgery in a midwestern medical school 404 Fellowship of Surgeons to carry with it an annual stipend. Accompanying the appointment was the position of chief of surgery at Barnes Hospital, an integral institution in the medical school's clinical teaching program. Thus, Graham became a "full-time" professor of surgery, a post quite foreign to his early environment and training. Having accepted the position, it was Graham's nature to believe that this was the only method of faculty relationship which a medical school should employ in the teaching of surgery. Argu- ments to the contrary on this debatable question, as in all other matters, were likely to be dismissed with scorn and blunt sar- casm unless his antagonist was direct and forceful in a logical presentation of his beliefs. Then Graham's dictatorial manner dissolved and he became a judicial, interested listener who, when convinced, would change his opinion and agree graciously.

A social revolution, which many observers believed had been in progress in the United States for three decades, had been accelerated. The medical profession, as a whole, had failed to realize this fact. Doctors were inclined to regard compulsory health insurance sponsored by the Federal Government as an isolated, new issue whereas it was only a small part of the growing movement to socialize the United States. The idea that the world owes every man a living had been accepted generally. As a corollary, the theory was advanced that the Federal Government would provide whatever the individual citizen felt disinclined to provide for himself. Industry and thrift were being left out of children's copybooks as cardinal virtues. Charity, either from private or public sources, was no longer abhorrent to a society which previously had demanded as its right only that it be allowed to enjoy the products of its own labor. The new Director of the College had spoken at the 1950 convocation in Boston. In referring to the time when he entered the Army Medical Corps, he said, "I left a society in which the only 'Freedoms' men demanded were freedoms to—not freedoms from something or other—not 'freedom from want' but freedom to provide against want by retaining the rewards of Fellowship of Surgeons 405 their industry instead of turning over the lion's share to an extravagant and incompetent government."' During this 20-year period of social and moral deterioration, great advances had been made in the history of American surgery. Responsible for this paradox were the influence of the American College of Surgeons upon the teaching and training of surgeons and the standards of hospitals and that of the Coun- cil on Medical Education and Hospitals of the American Medi- cal Association upon the improvement of medical schools. The new State of Israel had been admitted to the United Nations. The Federal Republic of Western Germany had been proclaimed in Bonn. Scientists in the Soviet Union had constructed and exploded an atomic bomb, thus ending the monopoly of the United States. Activities of the Communist party in the United States, Canada and Great Britain in securing information necessary for manufacture of the bomb were rapidly being exposed. Congressional committees were investigating the membership of the Communist party, and individuals who refused to answer whether or not they were members were convicted of contempt of Congress. These efforts to thwart the infiltrating tactics of the Communists into Government were balked by the Supreme Court ruling that under the fifth amendment to the Constitu- tion, no one could be forced to testify against himself. "Taking the Fifth" became a phrase of common usage. The revolt of factions of Afgentina's armed forces against the regime of Dictator Peron had been crushed. A general election in Great Britain returned the Conservative party to power. Attlee was succeeded by Churchill, who had been unceremon- iously removed from office immediately following World War II. Scandals of graft and corruption in governmental bureaus, including the Bureau of Internal Revenue, erupted in Washing- ton. The long control of the Federal Government by the Demo- cratic party appeared to be slipping. It seemed certain that General Dwight D. Eisenhower would be the Republican candidate for the Presidency. Hawley, Paul R.: Quo Vadimus? Bull. Am. Coll. Surg., 36:1, 1951. 406 Fellowship of Surgeons Immediately after Graham's election as Chairman of the Board, the Regents of the American College of Surgeons became concerned over the results of an action taken by the International College of Surgeons. In March 1946, the United States Section of that organization created the International Board of Surgery. Diplomas of the same general form as those issued by the established boards in surgery and the surgical specialties were awarded to doctors who were not able to meet the requirements of the existing American boards and the American College of Surgeons. The recipients of these diplomas were encouraged to use the distinction "Diplomate of the Inter- national Board of Surgery" as evidence of professional qualification. The Regents regarded this movement as a threat to the standards in surgery and graduate training in surgery which the American College of Surgeons had so long striven to elevate. The International Board of Surgery was functioning without the sanction of the Advisory Board for Medical Specialties under whose auspices all of the recognized qualifying boards were acting. After careful consideration of the implications, the Regents of the American College of Surgeons adopted a resolution on December 3, 1951.° This called attention to the significant contributions made in the elevation of the quality of care and treatment of the surgical patient, to the highest level yet obtained in American surgery, by the standards adopted and applied by the existing American boards for certification in general surgery and each of the surgical specialties. The Regents could find no logical justification for the establishment of other certifying boards in the same fields. It was the opinion of the Regents, clearly expressed in the statement, that the application of standards fixed by the board of the Inter- national College of Surgeons was not in accordance with the generally accepted principles of education and training upon which competence in surgery should be evaluated. It was futile to believe that most patients would be able to ° See Appendix, Chapter 13:1. Fellowship of Surgeons 407 distinguish between two standards for the certification of surgeons who were qualified to operate. The Regents deplored the creation of certifying boards other than those approved by the Advisory Board for Medical Specialties and regarded such action as a menace to the existing standards in the practice of surgery and to their further elevation. The Regents advised the Fellows of the American College of Surgeons not to support in any manner the establishment and perpetuation of any certifying boards other than those approved by the Advisory Board for Medical Specialties and not to support any organization which sponsored such boards. A copy of the resolution was sent to each Fellow of the American College of Surgeons and to members of each American board for certification in surgery and the surgical specialties. This mailing was completed February 27, 1952. The letter of transmittal to the Fellows was signed by Paul Hawley at the direction of the Board of Regents. It stated that the American College of Surgeons had never expressed any opinion or taken any position, nor did it by the action then taken, regarding the International College of Surgeons as an organization. The letter reiterated the belief of the Regents that the creation of "certifying boards" such as those condemned by the resolution was prejudicial both to the maintenance of the existing standards of surgical practice and to their further improvement. The letter also informed the Fellows that the In- ternational College of Surgeons had threatened to bring suit against the American College of Surgeons because of the resolution. On December 27, 1951, Norman Littell, General Counsel for the International College of Surgeons, United States Chap- ter, talked by telephone with Director Hawley. Littell stated that the resolution passed by the Regents was a direct attack on the International College of Surgeons and would have to be revoked. He claimed that it was a violation of the antitrust laws and that it invited a legal proceeding for treble damages. He said he considered the damages to be positively clear. It was alleged that several resignations from the International 408 Fellowship of Surgeons College had occurred as a result of the resolution. Littell indicated in the recorded conversation that, as General Counsel of the International College of Surgeons, he was preparing to go ahead with legal proceedings. A letter, dated December 31, 1951, signed by Norman M. Littell, and addressed to The Director of the American College of Surgeons, confirmed the telephone conversation. It also stated, "The purpose of my telephone calls was to put your organization on notice that appropriate legal proceedings would be instituted against the American College of Surgeons and the Regents thereof, and to afford an appropriate opportunity to mitigate damages by ceasing and desisting from all further action constituting offenses against the law and injuries to my client, particularly in view of the fact that treble damages are allowed in such cases." Littell visited Chicago and conferred with Beverly B. Ved- der, then General Counsel of the American College of Surgeons, in the latter's office on January 9, 1952. The two attorneys discussed the threat of a lawsuit. Vedder pointed out that since both corporations were nonprofit organizations claiming ex- emptions under the Internal Revenue laws, it might be embarrassing for the International College of Surgeons to allege that it was being damaged in its business and losing profits. Under date of February 18, 1952, Dr. George W. Lull, then Secretary and General Manager of the American Medical Asso- ciation, wrote to Evarts Graham, Chairman of the Board of Regents. The letter stated, "Last week, the International Col- lege of Surgeons requested the Board of Trustees of the Ameri- can Medical Association to appoint a committee to meet with them . . . and after discussing a number of problems the committee of the Board of Trustees decided to request a meeting with a committee from the American College of Surgeons in order to prevent any legal complications with the attending publicity which might arise and might be damaging to the whole medical profession." In the February 1952 issue of Postgraduate Medicine, Mor- ris Fishbein, who had retired as editor of the Journal of the Fellowship of Surgeons 409 American Medical Association, wrote an editorial, "Certifying Boards and the Functions of Medical Organizations." 2 Fishbein reviewed the creation of the certifying boards and the opposition to the International College of Surgeons by the Interna- tional Society of Surgery but failed completely to mention the establishment of the International Board of Surgery which was the sole point at issue. Fishbein's editorial contained interesting statements in comparison with those written in the Journal of the American Medical Association at the time of the organization of the International College of Surgeons. At that time, also, the comment of Time had been: "Dr. Thorek saw in Mrs. Hearst (Wil- liam Randolph) a likely patroness for a new International Col- lege of Surgeons which he was to help an old Manhattan friend, Dr. Harold Lyons Hunt, get on its feet in the face of denunciation by the American Medical Association's mouthpiece, Dr. Morris Fishbein."3 Fishbein's 1952 editorial read in part: . . . In the meantime the hostilities toward the International College of Surgeons waged by the International Society of Sur- gery under the leadership in the United States of Dr. Rudolph Matas and of the American College of Surgeons, now under the leadership of Dr. Paul Hawley, have not ceased. Nevertheless, the International College of Surgeons has been growing like a case of acromegaly. Why? Its director-general speaks many languages; he is dynamic; he is a master showman; he has gained the respect and cooperation of many surgical leaders in foreign countries who simply shrug their shoulders at American medical politics. . . . The International College of Surgeons, if kept within its fundamental purposes, can provide a sort of triumph of democracy among the aristocracy of surgery. . . . The newest leadership in the American College of Sur- geons seems to be indulging in a fit of petulance toward its rival, whereas similar attempts by both American and foreign groups to throttle it aborning failed in 1935 and 1936. The lusty

2 Fishbein, Morris: Certifying Boards and the Functions of Medical Organiza- tions. Postgrad. M., 11:2, 1952. 3 Time, 29:1, 19, 1937. 410 Fellowship of Surgeons infant now called the International College of Surgeons suffers noticeably from an inferiority complex and shudders at every complaint or criticism. . . . Paul Hawley wrote to Fishbein on February 29, 1952, with reference to the editorial: . . . You imply rather pointedly that the action taken by the Regents of the American College of Surgeons is merely a continuation of the opposition of the International Surgical Society —and, by the erroneous association of the term "leadership" with me in one place, that it was petulance on my part which prompted this action. Your explanation of the motivation of this action may be convincing in certain circles; but no one engaged in the training of young surgeons will be deceived. I can assure you that these implications in your editorial are entirely false. The resolution was directed NOT at the Inter- national College of Surgeons but at an action of that organization which, in the opinion not only of the Regents but also of the great majority of the supporters of high standards in surgery, is inimical both to the preservation of present standards and to their further elevation as time and experience may indicate. The covering letter accompanying the resolution also makes this clear. . . . Evarts Graham, Chairman of the Board of Regents, would not agree to confer with representatives of the International College of Surgeons when, as he said, "The organization is threatening to bring a legal suit against the American College of Surgeons and each of its Regents." The Fellows of the International College of Surgeons received a letter from Max Thorek in March 1952, which might indicate that the lines of communication between him, the General Counsel and the Executive Council of the International College were not always clear. "In order to clarify the situation," Thorek wrote, "I am enclosing some literature which will show that the attack upon the International College of Surgeons was engi- neered neither by the American Boards nor the American Col- lege of Surgeons. I am being told it is the brain child of, as he calls himself 'THE DIRECTOR', one Hawley." Fellowship of Surgeons 411 The implication that Hawley was largely or solely responsible for the resolution of the Board of Regents, adopted December 3, 1951, was without foundation. The statement was prepared by the Board of Regents and adopted by unanimous vote. Hawley's only action was to sign, as the executive officer of the Board and at its direction, the covering letter which accompanied the statement when it was distributed to the Fellow- ship of the College. The Board of Trustees of the American Medical Association recommended that the House of Delegates reiterate its previ ously established position that the American Medical Association recognizes and approves only one certifying board in each of the specialties of medicine, namely, those boards established by the Advisory Board of Medical Specialties and the Council on Medical Education and Hospitals. The statement of policy at "it is not in the interest of medicine or of the public for other medical organizations to establish certifying agencies" was adopted by the House of Delegates during its meeting of e- cember 2-5, 1952, a year after the Board of Regents had initated action. Anyone who knew Graham well would understand that as the chairman of the committee which organized the American . Board of Surgery, he would take the establishment of the International Board of Surgery as a personal affront As Chair- man of the Board of Regents, he appointed a committee of three to draft the resolution adopted by the Board of Regents, He was somewhat offended that the personal attack had not been made against him alone. However, he found a personal reference in the November 1953 issue of Missouri Medicine, the journal of the Misseind State Medical Association, which contained an editorial mot k stated that Dr. Evarts Graham was elected president of the International College of Surgeons instead of the International Society of Surgery.' Graham immediately wrote the editor, stating that he as sure it was an unintentional mistake which had cause . km to Members in the News. Missouri Med., 50:11, 1951 412 Fellowship of Surgeons suffer "by gratuitously bestowing" on him not only membership but the highest office in the International College of Surgeons. He said he was not only entirely out of sympathy with the "parvenu organization known as the International College of Surgeons" but had a particular abhorrence for it because there was a suit for damages threatened by that organization against the American College of Surgeons and him as Chairman of the Board of Regents. Graham was one of the last of the old school of doctors in the United States who would have picked up with gusto every gauntlet tossed down by Philip Mills Jones in the early days of the formation of the American College of Surgeons. Graham ended his letter to the editor by saying, "I cannot afford to let people think I am even a member of the Inter- national College of Surgeons to say nothing of allowing my name to be put up as President of such an outfit." 5 Max Thorek's answer appeared in the February 1954 issue of Missouri Medicine. 6 He wrote that Graham was guilty of a misstatement when he said that a suit, instituted by the Inter- national College of Surgeons, was pending against the American College of Surgeons. Thorek accused Graham of claiming priority for performing the first successful pneumonectomy. He claimed this rightfully belonged to Professor Rudolf Nissen of Basel, Switzerland. Thorek also stated that there was an e;:cellent co-operative spirit between those surgeons who were members of both Col- leges. He reached out and sought support from the American Academy of General Practice, "the backbone of organized medicine," which he said was also an object of Graham's attack. Graham's answer was long and detailed.? He recited the facts which formed the basis for his statement about a threatened legal suit. He castigated Thorek for attempting to correct him about the title of the office he held as president of the 16th Congress of the Societe Internationale de Chirurgie. Graham

5 Letters to Missouri Medicine. Missouri Med., 50:12, 1953. 6 Letters to Missouri Medicine. Missouri Med., 51:2, 1954. 7 Letters to Missouri Medicine. Missouri Med., 51:5, 1954. Fellowship of Surgeons 412 was particularly outraged by Thorek's statement that he had attempted to steal from Professor Nissen the priority of performing the first total removal of a lung. In his published article he had referred to Nissen's and Haight's cases in which the hilus was ligated and the lung was gradually allowed to slough out. Graham had removed a long for cancer, the first time this had been done in a single stage for any reason. The editor of Missouri Medicine became the innocent bystander in a polemic which threatened to become more and more personal. However, Graham had the last word in a battle precipitated by an uncorrected typographical error. Quite unin- tentionally, a state medical journal had publicized the differences of philosophy between the American College of Surgeons and the International College of Surgeons regarding surgical training. Unfortunately, it was assumed by many that these differences were based upon the personalities of individuals in the two organizations. It required a long time for many surgeons to understand that the American College of Surgeons was attempting to maintain the standards of surgery for which it had fought so many years. So often the principles at issue are lost in the confusion and smoke of controversy engendered by contradictory statements of fact and fiction. In the mind of Evarts Graham, any attempt to lower the standards for the training of young surgeons was in the same category with unethical surgical practices. Both were to be fought with strong frontal attacks. Graham believed that his predecessors as Chairmen of the Board of Regents were overly diplomatic and cautious. The fight within the profession, which was bound to follow statements that the medical profession should take action against unethical practices, and the attendant publicity, which could not be avoided in the presence of more modem media of communication, would have been distasteful to Irvin Abell and Arthur Allen. Graham had always believed that the American College of Surgeons should be more aggressive in its opposition to fee- splitting, unnecessary operations, ghost surgery and other un- 414 Fellowship of Surgeons ethical principles. His short experience in practice in Mason City, Iowa, had made him impatient with the dilatory actions of the Board of Regents. His service as a Regent had not tempered his patience. He had learned, however, that it was one thing to suspect a surgeon of secretly dividing the surgical fee with the referring physician and another to furnish proof sufficient to proceed with expulsion from the College. In the minds of many people, a rapid rise in success in surgical practice is most easily attributed to unethical financial transactions, either forgetting or ignoring the fact that real merit in surgery often brings its own reward. Still others with selfish purposes do not hesitate to start rumors of fee-splitting in the case of a fellow surgeon because they know how difficult it is to prove or disprove the validity of such statements. In cycles, these unethical practices had plagued the Board of Regents from the beginning of the College. In some areas of the country, Fellowship had been granted to surgeons who formerly had secretly divided the surgical fee but who had been willing to sign the pledge of the College against fee-splitting and abide by it. There was no doubt that those converts had become an influential factor in their respective communities in promulgating the ideals of the College with respect to the proper financial relations among surgeon, physician and patient. A movement had been initiated to refuse Fellowship to all surgeons who in the past had been guilty of fee-splitting. The administrative board of the College had struggled ineffectively with the problem and had characteristically recommended that it would be wiser to leave the decision in individual cases to the local credentials committees. Now ghost surgery, unnecessary operations, exorbitant fees and itinerant surgery were added to the list of malpractices. Paul B. Magnuson, who had succeeded Paul Hawley as Medi- cal Director of the Veterans Administration, urged that the College lay the cards on the table," say what the practices had been under certain conditions and have the story written Fellowship of Surgeons 415 up for the Reader's Digest and the Saturday Evening Post. Magnuson said that he could give the American Medical As- sociation the names of men who were guilty of splitting fees, but that organization could only turn the names over to the respective county medical societies and no action would be taken. There were loud rumblings elsewhere in 1948, but the Ameri- can Medical Association was vigorously attacking another unethical practice. The Board of Trustees and all the officers signed an editorial demanding that physicians stop accepting rebates, "kickbacks" and commissions on prescriptions for eyeglasses, supplies and appliances from optical companies and laboratories. Commercial x-ray laboratories in southern California were rebating from 50 to 80 per cent of the fee collected from the patient to the referring physician. The Better Business Bureau of Los Angeles sent a mimeographed communication to each member of the council of the Los Angeles County Medical Association inviting co-operation, assistance and advice in a campaign to do away with medical "kickbacks." The California Medical Association announced to the press that it was taking action through the state legislature to outlaw rebates. This was a tiny fragment of the problem of unethical practices which had become customary in the medical profession. How- ever, it was clear that any campaign to change these practices should come from medical societies and be directed by the profession. It was upon such fare that state medicine and its socialistic champions would thrive. Albert Deutsch, a free-lance writer, wrote "Unnecessary Op- erations" which was published in Woman's Home Companion!' Another free-lance writer, Greer Williams, wrote a factual and interesting article entitled "The Truth About Fee-Splitting."a Labor leaders in Will County, Illinois, gathered information

° Deutsch, Albert: Unnecessary Operations. Woman's Home Companion, 741 32, 1947. 9 Williams, Greer: The Truth About Fee-Splitting, The Modern Hospital, 70.2 1948. 416 Fellowship of Surgeons concerning medical practices in their community. In a weekly newspaper, several statements were made. 1° It was said that a high percentage of doctors in the community did not do surgery themselves but employed "ghost surgeons" to do their work. The article defined a ghost surgeon as one who does not enter the operating room until the patient is asleep and so the patient has no knowledge of his presence. It was charged that in many cases the attending doctor did not advise his patient or the relatives that he would not perform the operation. Sometimes the family doctor would let it be known that a certain doctor would assist him, when in fact the other physician was the surgeon employed to perform the operation. The surveyors found that the number of doctors in their community who had voluntarily sought residency surgical training was extremely small. The fee paid to the employed surgeon was often ridiculously small compared to that charged the patient. It was frequently as low as $25 for an operation. This practice was so common that physicians who employed surgeons to operate for them at that fee were spoken of as members of the "Twenty-Five Dollar Club." These labor union officials declared that fee-splitting was a common practice in Joliet, Illinois; that patients were sent into the hospital such a short time before operation that little or no time was available for a careful study of the patient's condition. If the ghost surgeon did not entirely agree with the employing physician as to the type of surgical procedure which should be performed, he would have to follow the physician's desires fairly closely or he would lose his work. Some communities of surgeons recognized their responsibility for the disciplining of their own ethical professional habits. The Surgical Society of Columbus, Ohio, required each of its members to sign the pledge of the American College of Surgeons and an agreement to submit office records, accounts and income tax returns for annual audit. The board of trustees of each

10 The Labor Record, 14:13, 1947 (December 11), The Labor Record Publish- ing Co., Inc., Joliet, Illinois. Fellowship of Surgeons 417 hospital then agreed that only Columbus Surgical Society members could hold positions on the surgical staffs. Since January 1, 1946, fee-splitting has become practically nonexistent and the total number of operations performed in Columbus hospitals has decreased. At the instigation of Malcolm MacEachern, the College had asked hospitals to enforce the "Principles of Financial Relations in the Professional Care of the Patient," which the Board of Regents had circulated in 1940 in a continuing effort to delineate accurately financial doctor-patient relationships. A few statements were added to those originally made by the Board of Regents, all of which were made necessary by the gradually changing social and economic conditions. Some were taken for granted; some were subject to various interpretations which caused confusion. The "Principles" stated that each doctor participating in the care of a patient should be entitled to compensation commensurate with the services rendered to the patient. However, nothing was said about the patient's ability to pay in relation to the services given. The doctor should acquaint the patient with his financial responsibility to all those physicians concerned with his care. Each doctor should give or send directly a detailed statement showing the fees charged for his professional services. The use of one doctor's billhead for a combined fee for services should be avoided and was warned against as a subterfuge for fee- splitting. Hospitals should not determine or collect fees for doctors; thus, a third person should not enter into the financial relations between doctor and patient. A referring physician should not be used as an assistant or an anesthetist at an operation unless his training and continuous experience make him competent in either or both duties. On October 27, 1950, Walter C. Bornemeier, a Fellow of the American College of Surgeons and secretary of the Chicago Medical Society, sent a copy of a statement he had written on fee-splitting to Arthur Allen, Chairman of the Board of Regents. 418 Fellowship of Surgeons Bomemeier wrote, "To date I have seen no definition that logically explains exactly what is criminal and what is not criminal when two or more doctors divide a fee rendered for care in a single illness. Group practice is being recommended as the best type of care. Yet, when two or more doctors having separate offices co-operate in the care of an illness, someone must watch with jaundiced eye to be sure that separate bills are rendered." Bomemeier believed that the general practitioners, internists and pediatricians had been legislated against and advocated a combined bill which would state the names of all the doctors receiving a portion of the fee, but the patient would be cognizant of only one total fee. A professional relations committee was appointed by the Board of Regents to report upon all of these principles of ethics and practice which were being discussed so widely in the public press?' The Regents and the committee attempted to define and describe every possible situation in the doctor- patient relationship.. The first report was followed by a second on November 9, 1951." Several situations had been cited and the College had been asked to give its interpretation of whether or not the procedures employed were unethical. The report defined fee-splitting as a practice in which part of the fee a patient pays to a physician or a surgeon is given, through some subterfuge and secretly, to a third party, usually the physician who referred the patient to the surgeon. In "ghost surgery" the surgeon is paid for his services by the patient's doctor and is unknown as an individual to the patient or his family, who may be led to believe that the "family doctor" has performed the operation. A clinic or a private physician paying a salary to another physician as compensation for sending patients to that clinic or physician is also fee-splitting.

11 The Committee on Professional Relations made its first report on April 13, 1951. The committee consisted of Warren H. Coln, Chicago, chairman; Joel W. Baker, Seattle; Ralph Co1p, New York; W. Edward Gallie, Toronto; E. Eric Larson, Los Angeles; Thomas G. Orr, Kansas City; and I. S. Ravdin, Philadelphia. * See Appendix, Chapter 13:2. ** See Appendix, Chapter 13:3. Fellowship of Surgeons 419 Rebates, commissions or "kickbacks" on the charges made by a company for an appliance, test or medicine were considered a form of fee-splitting. If the referring physician acted as an assistant at the operation, gave the anesthetic or provided the postoperative care for the patient and received payment for those services from the surgeon, fee-splitting was being practiced. The subterfuge of having the referring physician perform such services to demand adequate remuneration for his medical responsibilities to the patient was not justified. The committee had to compromise by saying that in the absence of a qualified surgical assistant or resident in training, it would not be unethical for the referring physician not specially trained in surgery to assist with the operation, providing each doctor sent his own bill. The committee finally answered Bornemeier's plea for combined bills by classifying them as undesirable and unethical even when the doctor's charges were itemized. A distinct difference existed in bona fide clinics, the members of which were on a prearranged salary or partnership basis. Likewise, in hospitals where the medical staff authorized the hospital to send combined bills for physicians' services, the procedure was ethical if the bills were itemized. Insurance companies and their persistent opposition to bills from several doctors who gave care to the same patient caused compromises which some of the Regents ineffectively opposed. Because insurance companies did not wish to complicate their bookkeeping systems, they insisted on a single bill which would be allowable in accident and health insurance claims. This, the committee said, would be allowable, but "it is paramount that the patient be informed exactly the amount due and payable to each physician." Time was to prove that this provided a convenient method of dividing the surgical fee. The report called attention to the fact that the general practitioner frequently does not receive proper compensation for his initial role in caring for the patient. It was recommended strongly that surgeons emphasize to the patient the great value 420 Fellowship of Surgeons of good medical judgment in making the original diagnosis and carrying out the preliminary medical treatment. Overcharging by the surgeon was not only unjust but, "moreover, it encourages fee-splitting because the patient's financial reserves are so depleted that the referring physician cannot be paid adequately for his medical services." Surgeons should be educated to the fact that their fee should be determined by other medical expenses, the services rendered and the patient's ability to pay. In adopting the committee's report, the Board of Regents had to all intent and purpose written a code of ethics in some respects far more specific and binding than that of the American Medical Association. It was a significant commentary that it had become necessary to expand a code of medical ethics beyond the statement that it should be a rule of simple honesty. Thus, it became necessary to enumerate and define acts of dishonesty. The layman has often asked, "Why all the commotion and fuss about fee-splitting among doctors? Lawyers pay 10 per cent of the fee to the attorney who referred the client to them." Thus, the practice is separated from its byproducts when considered by the average citizen. However, the evils which accom- pany fee-splitting are an integral part of the act. Secrecy may be said to be the lesser of the evils. To withhold information from the patient is to violate the frankness and honesty which should exist between doctor and patient. If, as its defenders argue, it is not against the patient's interest, why the necessity for secrecy? That element in the practice alone con- victs it. The greater evil of the practice is that of inducement, as Paul Hawley has insisted. Any method of inducement is regarded by the American College of Surgeons as fee-splitting. A doctor has the moral and professional obligation to treat his patients exactly as he would have himself or a member of his family treated under similar circumstances. He is guilty of a moral crime if he refers his patient to a doctor into whose care he would not place himself. This is a complete disregard of the interests of the patient who is referred—one may even say sold— to the unscrupulous surgeon who pays the highest price. Fellowship of Surgeons 421 The Regents maintained that concealment enables the family doctor to depend on the surgeon for his compensation. He may charge his patient a negligible fee of his own or appear magnan- imous in apparently foregoing a fee entirely. The patient needs to trust his physician because of the psychological effect of faith in one's doctor. Inducement, if not concealed, would shake that trust. A sick man seeks a safe sanctuary free from commerical exploitation. Some encouraging signs of progress appeared in the College's more widely publicized fight against fee-splitting. Three hospitals in Bloomington, Illinois, finally succeeded in combating the practice among their staff members by disciplinary action. In the course of the achievement, the American College of Surgeons was denounced as "a communistic organization," headed by "a Joe Stalin" who sought to create a "dictatorship of surgery" and to sponsor "socialized medicine." A new avenue of attack against the practice appeared from another source. Several Internal Revenue regional directors had taken the position that split fees were not allowable as business deductions. However, the Commissioner of Internal Revenue had not issued such a directive to establish a nationwide policy. At its meeting in April 1952, the Board of Regents adopted the view that a split fee is against public interest and is not a necessary act following the performance of surgical operations. This action was transmitted to the Commissioner of Internal Revenue. The Regents believed that their statement might be of help to the Bureau of Internal Revenue in view of a ruling made by the United States Supreme Court. On March 10, 1952, the Supreme Court had ruled in behalf of Thomas and Helen Lilly, North Carolina opticians, that the income tax deductions they took for "kickbacks" to ophthalmologists on eyeglasses sold to their patients were ordinary and necessary business expenses. This ruling reversed the position of the Commissioner of Internal Revenue who had successfully argued throughout the lower courts that a business deduction of a "kickback" was not allowable because it was medically unethical and against public 422 Fellowship of Surgeons policy. It appeared that the hope of controlling fee-splitting by the necessity of paying income tax had been destroyed. As a matter of fact, some doctors interpreted the Supreme Court's decision as constituting legal approval. Due to difficulties with the Bureau of Internal Revenue, several members asked their Iowa State Medical Society to elaborate upon the Society's code of medical ethics. The case for the methods of practice in Iowa was presented in a letter written to Paul Hawley, The Director, by Dr. W. L. Downing, a Fellow of the College from Le Mars, Iowa.12 Downing referred to the experience of his father, a general practitioner in a small Iowa town, who referred his patients to a surgeon in the county seat about 15 miles away. The senior Downing assisted in the operation and continued the care of the patients when they returned home, charging a fee for his services. Downing said that soon the patients went directly to the surgeon, thinking they would save the fee they paid his father, their physician. As a result, his father's surgical patients became fewer and fewer. However, the patients were quite unable to understand why Downing's father did not know all about their case or why he was not pleased to see them as an emergency during the middle of the night, often when he had to drive a team or his automobile over practically impassable roads. Downing's letter defended a single fee, stating that in his practice the patient was always told that one charge would compensate all the physicians who took part in his care. Rarely, he said, did a patient ever ask how the fee was divided. In fact, he believed the patients liked that method of doing things. Downing emphasized the difference between such a method and the secret division of the fee to the referring physician who did not assist in the care of the patient. - Downing criticized the Regents because they were professors of surgery in medical schools and he questioned what they knew about the problems of surgical practice in small communities. He was fearful that the general practitioner would

12 Two Physicians Speak Their Minds on Fee-Splitting. Bull. Am. Coll. Surg., 37:4, 1952. Fellowship of Surgeons 423 become obsolete in small communities if he continued to be barred from hospital staffs and was refused operating room privileges. Dowing summarized his argument thus: If the ethical and capable surgeons of the country will utilize the general practitioner in caring for his surgical patients, use him to the extent of his capabilities both in diagnosis, counsel- ing, operative assistance and care and charge a joint fee and divide it equitably with the full knowledge of the patient, "fee- splitting, secret division for mere reference" will soon be a thing of the past. . . . Downing's original draft of an elaboration of the code of ethics for the Iowa State Medical Society was adopted after revision by the executive council of the Society in March 1952. 13 Hawley answered Downing's letter in the same thoughtful and considerate vein. He could not agree that the general practitioner was always as competent as a surgical assistant. Neither had he the ability to care for the patient, either pre- or postoperatively, as did a well-trained surgeon. Hawley emphasized that the general practitioner, particularly one who tried to be first-class, should be held in the highest respect. The elaboration of the code of medical ethics, he said, stated that reward or financial gain is subordinate to rendering service to humanity and thereafter dealt only with financial gain. Hawley's belief was that: . . . the sin that is killing the practice of medicine—in all of its specialties—is greed. This is a disease of our times. It is not limited to medicine, and it did not start in medicine—it has merely spread to medicine. When money begins to exert even the slightest influence in the practice of medicine, medicine ceases to be a noble profession and becomes a vulgar trade, subject to antitrust laws and suits for restraint of trade— which humiliation we have already experienced. . . . At their meeting in December 1952, the Regents stated in a

13 Downing, W. L.: Draft of a Code of Fees et cetera for General Practitioners and Specialists. Bull. Am. Coll. Surg., 37:4, 393, 1952; Elaboration of medical Ethics by Iowa State Medical Society. Bull. Am. Coil. Surg., 37:4, 394, 1952. 424 Fellowship of Surgeons resolution that the elaboration of medical ethics published by the Iowa State Medical Society was contrary to the principles which had guided the American College of Surgeons since its organization. The Regents accepted the resignation of Donald Conzett from the Board of Governors. Conzett, then president of the Iowa State Medical Society, stated that the principles of the College were ideal but impractical. They also voted to defer serious consideration of all candidates for Fellowship from Iowa until the situation could be studied and until a credentials committee upon which the College could depend to support its tenets could be established in the state. At the first meeting of the Board of Regents, the problem of fee-splitting in Iowa occupied an inordinate amount of the time of the Regents. Forty years later the same question arose, but it was being considered by the policy body of a firmly established surgical organization which had made many contributions to the elevation of the care of the surgical patient. The publicity attending the position of the College on fee- splitting drew criticism. The president of the Medical Society of the County of New York registered official regret and deep concern on behalf of a minority committee of the society over the publicity which followed the remarks made by Alton Ochs- ner, President of the College, upon fee-splitting. Members of the Society were distressed because the implications of Ochsner's remarks smeared New York doctors as well as those in the rest of the country. They stated that fee-splitting in New York City was limited to a small minority because it was both an unethical and an illegal practice. Certain science writers and reporters who covered the Clin- ical Congress in New York City in September 1952 requested the opportunity to discuss frankly with the Regents of the College the problem of fee-splitting. After serious deliberation, the Re- gents agreed to such a conference, and 13 representatives of the College attended with eight members of the press, including several of the nation's leading science writers. Never before, it was said, had the responsible officers of any national medical or surgical organization shown the willingness, Fellowship of Surgeons 425 let alone the courage, to submit to a round-table discussion of the ethical problems of medical practice with representatives of the press. The newspaper men wanted to know just what was so bad about fee-splitting, what was the College doing about it, what were other medical organizations doing, what could the public do and just where did fee-splitting exist. In the course of the discussion, the Regents emphasized the evils of inducement and all of the other facets of the practice to which they had objected throughout the years. They also called attention to the fact that fee-splitting in any community tended to exclude the young, well-trained, ethically conscientious surgeon who sought to establish himself in a strictly surgical practice. Having done everything to encourage young doctors to seek competent training in scientific surgery, the Regents said they had repeatedly received complaints from young surgeons that they were subject to discrimination and trade-union tactics. The pressures upon these men with high ideals were mounting day by day. It was made clear that fee-splitting worked not only against the best interests of the patient by introducing a financial consideration in the choice of surgeons but also against the public's ultimate benefit derived from elevating the quality of the surgeon's training and improving the results of surgery. News stories of the conference were carried in 338 newspapers, in 36 of which editorials were written. The Boston Globe commented that it was rare indeed when the leaders of any group initiated a reform to apply to persons in their own line. The Bergen Evening Record of Hackensack, New Jersey, told its readers: The American College of Surgeons, treading on one of the medical profession's touchiest toes, says that fee-splitting is an unethical practice, hard to detect, and harmful to the patient. This much everyone knew. What gives hope that the evil may be curbed is the frank manner in which the College has discussed it and asked the public to help. Hitherto fee-splitting has been like venereal disease was a few years ago; it existed, but nice people did not talk about it. . . . 426 Fellowship of Surgeons Many doctors objected to the intentions of the College and to the resulting newspaper publicity. Loyal Davis, one of the Re- gents present at the discussion, in answer to a direct question from the press representatives, ventured to state that fee- splitting was on the increase in Chicago and the surrounding areas. Davis was thus quoted in a Chicago newspaper. According to "hospital corridor" gossip, certain Chicago general practitioners were irritated when their patients read the newspaper article and asked them if they split fees. In any event, about 150 physicians, all members of the Chicago Medical Society, most of them general practitioners and a large number from the staffs of two hospitals, signed petitions charging Davis with (1) making statements for personal publicity advantages, (2) releasing misleading information, and (3) making statements detrimental to the entire medical profession. The Society was called upon to investigate and expel him. The Society released information to the press on its accusations before Davis received official notification of the charges placed against him. Only on demand were the names of the petitioners furnished to him before the date of his summons to appear before the Society's Committee on Ethical Relations to defend himself. Previously, there had been a concerted effort by some members to adopt a resolution then pending before the Society proposing that the code of ethics be re-defined to make fee-splitting ethical. The response of the newspapers in Chicago was to come to

Davis' defense. The Chicago Sun - Times said: Too frequently it has been the policy of individual businessmen and certain business organizations to complain bitterly against criticism rather than do their part toward correcting the conditions criticized. It doesn't take a particularly smart man to recognize that this is the wrong approach. Chicago doctors currently are supplying another example of this type of attitude. . . . If they had asked the Chicago Medical Society to make an impartial study of the matter and then make public its findings, they would have attracted public support. As it is, one gets the impression that they are attempt- Fellowship of Surgeons 427 ing to cover up, that they would silence all further criticism by those on the inside who know the facts. . . . The Chicago Daily News commented: Physicians as a group . . . still have much to learn about the art of public relations. . . . The ouster effort seems to be a sanctimonious attempt to silence a critic without bothering to refute his charges. The energy would be much better spent in combating the evil of which Dr. Davis complains. . . . The Chicago Daily Tribune stated: Dr. Davis was not sounding off on some curbstone when he said that the practice seems to be increasing in Chicago. He was speaking at a news conference with science writers, organized by 13 officials of the College, who spoke in its name, to organize public opinion against a practice that hurts the public. . . . The medical society should be taking measures to stamp it out and the more responsible members, it can be predicted, will do so. . . . In the subsequent hearing before the Committee on Ethical Relations of the Chicago Medical Society, the truth or falsity of the statement was not discussed. In two later meetings of the Council which considered the charges and which Davis was not allowed to attend or be represented, there was no discussion of the charge that fee-splitting was increasing. Consideration was confined to whether Davis was guilty of unethical conduct as a member of the Chicago Medical Society in making a public statement as a Regent of the American College of Surgeons. It was contended that he should have first obtained permission from the Medical Society. It was also argued that the American Medical Association was the only national medical organization which represented the profession; an argument which had been made over and again in the past. There were also indications that the American College of Surgeons was the real defendant. The Judicial Council of the American Medical Association made a decision at the clinical session of the Association in Den- ver, December 2-5, 1952, which was an answer to those who 428 Fellowship of Surgeons repeatedly referred to the American College of Surgeons as a "minority group" attempting to force its own will upon the entire medical profession. Citing Section 5 of Article VI of the Principles of Medical Ethics, the Council ruled: This means that the physician who takes a patient over for treatment from another physician should render a bill direct to the patient for such treatment. If this happens to be a surgical case and the doctor referring the patient assists in the operation, gives the anesthetic or participates in any way in the treatment of the patient, the doctor so participating should render his own bill direct to the patient, and it should not be a part of the surgeon's bill. The Judicial Council has held many times that when a surgeon renders a bill for his fee it should not include bills from colleagues who act as assistants or anesthetists, but these colleagues should render their own bills. . . . A patient is entitled to the best treatment possible and a physician referring a patient to a consultant should select the consultant because of his ability and not because of pecuniary gain to the physician referring the patient." These statements were adopted by the House of Delegates and became the official position of the American Medical As- sociation upon the division of fees. This decision disposed of the specious arguments which had been advanced that pre- and postoperative treatment by the referring physician were inseparable from the specialist's services. There could be no further doubt, as Hawley pointed out, whose ethics were being enforced by the American College of Surgeons—they were the code of the American Medical Association. Other questionable practices appeared to be increasing, or perhaps were becoming revealed, as the standards for the training of surgeons and the management of hospitals were reaching higher levels. Inadequate control by hospital staffs over the character and quality of the surgical procedures performed was followed by poor results and unindicated operations.

14 Fee Splitting. Report of the judicial Council, J.A.M.A., 150:17, 1706, 1952. Fellowship of Surgeons 429 In 1952, an article entitled "Effectiveness of Hospital Tissue Committee in Raising Surgical Standards" was published in the Journal of the American Medical Association." The records of two surgeons in one hospital were compared with reference to the appendectomies which each performed. During the period studied, one of the surgeons had performed 25 appendectomies. In 13 of these instances, the appendix upon microscopic study showed no evidence whatever of disease. The article listed what the authors termed unnecessary hysterectomies, uterine suspensions and cesarean sections. The patients' records had been studied by a group of competent physicians and surgeons. It was pointed out that following such a medical audit the number of questionable surgical cases immediately decreased. This presentation of material was confirmed by medical audits carried out in a New Jersey hospital in 1949, 1950 and 1951. The unweighted average of normal appendixes removed by 10 surgeons on the staff of the hospital in 1949 was 23 per cent. After medical audits had been in effect for two years, this percentage dropped to two. In the same hospital, the amount of normal tissue removed during gynecological operations dropped from 11 per cent in 1949 to 2.5 per cent in 1951. Dr. Warren F. Draper reported to the American Medical Association the experience of the program of the United Mine Workers of America in providing medical care for its members." Draper stated the findings bluntly: . . . Closely related are the services performed by physicians who know they are not qualified for certain work, but who will attempt almost anything in order to retain the fee. The results are often gruesome...... Unnecessary surgery performed by reasonably competent physicians who know better, but want the money, is hard on the patient and deprives other patients of much needed service that could be provided by the money wasted. . . .

15 Weinert, H. V., and Brill, R.: Effectiveness of Hospital Tissue Committee in Raising Surgical Standards. J.A.M.A., 150:10, 992, 1952. 16 Draper, W. F.: Conference on Medical Care in the Bituminous Coal Mine Area: Views and Suggestions. 151:10, 848, 1953. 430 Fellowship of Surgeons Draper stated that he had appealed directly to state medical societies after placing the facts before them. This had resulted in a tedious, wearing and generally unsatisfactory process that discouraged repetition. Draper stated that state medical societies were reluctant to act because the right of any doctor to undertake all types of surgery might then be seriously questioned and patients would demand consultation and a qualified, trained surgeon. It was quite obvious that other labor organizations, the Gov- ernment and the public in general were aware of irregularities. Some doctors believed that the existence of the evils which they freely admitted should be kept secret. The question arose as to whether the medical profession or the public should take the lead in getting rid of the unethical practices which existed. The Regents firmly believed it was their duty to continue vigorously to elevate the standards of surgery and to oppose just as forcefully all movements to lower or violate the ethical principles governing the relations between patients and doctors. The Regents believed that the public is interested in the ethical principles which should be applied to relations between patient and doctor with reference to financial arrangements, indications for surgical treatment and the qualifications and identity of the surgeon. It was inconceivable to them that the medical profession as a whole could be injured by exposing those relatively few who violate or evade the historically high traditions of the profession. The editors of U. S. News & World Report requested an interview with The Director of the College to obtain background material for an article to be written by one of their staff. The request was granted with the understanding that any article written would be submitted for criticism before publication. The interview was held and recorded. Later, in the absence of The Director from the country, it was submitted to a member of the administrative staff of the College and edited as an interview and not as an article for publication. The interview was an informal conversational one and was so recorded. It was Fellowship of Surgeons 431 published in question-and-answer form and, as Hawley stated later, the language of informal conversation rarely looks well in print. However, he hastened to add that he was not misquoted." The interviewers questioned Hawley about the unethical practices in medicine and how in many respects medical ethics differed from the ethics of the legal profession. The story of fee-splitting, the evidence that many operations were being performed without good indications for surgery and the principles by which patients can select a qualified surgeon were discussed. The role of the family doctor in the care of a patient requiring surgery and the basis upon which doctors, particularly surgeons, should charge patients for their services were described vividly in a manner which lay readers of the magazine could easily understand and appreciate as being applicable to situations in which they had at one time or another found themselves. The rising standards of care in hospitals, the introduction of medical audits, another voluntary disciplinary yardstick placed upon themselves by doctors, and the aim of the entire medical profession to raise its level of patient care higher and higher were other topics of interest to the editors for presentation to their subscribers. The storm which broke over Hawley's head and around the American College of Surgeons was unprecedented. Eleven resolutions were introduced into the American Medical Association's House of Delegates at its meeting in New York on June 1, 1953. All condemned the College and/or The Director for publicity denouncing unethical practices in surgery. On the following day, the Reference Committee on Legisla- tion and Public Relations of the House of Delegates conducted a hearing on the resolutions. It was recommended that no action be taken upon any of the resolutions, which were considered jointly, but that a statement by the Reference Committee be substituted. The House of Delegates unanimously adopted the substitute statement. Again, the main contention was that statements relating to

17 Too Much Unnecessary Surgery. U. S. News 6- World Report, 34:8, 47, 1953. 432 Fellowship of Surgeons ethical matters by organizations other than the American Medi- cal Association advance the views of only a particular group and do not carry the official sanction of the entire profession of medicine. "The Principles of Medical Ethics as formulated, interpreted, and applied by the American Medical Association must be considered the only fundamental and controlling application of ethics for the entire profession," the statement read. Two of the 11 resolutions requested the development of an approved method for sending joint bills to patients. The committee called the attention of the House of Delegates to the opinion of the Judicial Council regarding fee-splitting and methods of billing for services to patients. No doubt, the opinion was correct that only the House of Delegates carried the authority to speak for the confederation of county and state medical societies. One of the paragraphs in the statement re-emphasized this opinion: Your reference committee believes that the harm done to the public and to the profession by the current articles which lower the confidence patients have in their doctors cannot be objec- tively evaluated. This highlights the fact that, when individuals or groups without official status in the American Medical Associ- ation utter or publish ill-considered statemerts, the result too often is that the confidence of the public in the medical profession is placed in jeopardy. However, the committee members said that the House of Delegates was devoted to the principles of American democracy which included the right of free speech. They then criticized broad generalizations, destructive critical comments and ill- advised and poorly prepared statements which failed to convey the intended meaning. Human nature, the committee said, made it certain that some physicians would probably always violate medical ethical practices. It was admitted that the method for disciplining such members of the American Medical Association was far short of perfection but was still the best and most practical means of correcting the abuses and safeguarding the best Fellowship of Surgeons 433 interests of the public. These methods of discipline all reside in the local county medical societies. The House of Delegates approved the recommendation of the Council on Constitution and Bylaws that it wished to study the proposals submitted for changes in the code of ethics which would permit the division of the patient's fee. Acting upon resolutions which had been presented, the Con- gress of Delegates of the American Academy of General Practice urged members of its various state chapters to request thorough inquiry, review and remedial action by their local county and state medical associations on the subject matter of the Hawley interview. An article entitled "Why Some Doctors Should Be in Jail" by Howard Whitman appeared in the October 30, 1953, issue of Collier's.18 Immediately, Stanley R. Truman of Oakland, Cali- fornia, a past president of the American Academy of General Practice, stated that the officers of that organization were be- sieged by telegrams, letters and telephone calls from members demanding that the article be answered. In Truman's reply he stated, "Our Democracy exists on the foundation of an informed public. The medical profession is not a priesthood within whose ranks their behavior and methods are to be kept secret.") Pointing out that he found no false statements in the Whitman article, he asked, "Then why all the hullabaloo?" If the members of the Academy of General Practice were against fee-splitting, rebating and ghost surgery, let them do something about it, said Truman. He suggested that a firm public statement be made against unethical practices and that the Academy of General Practice develop a program of action co- operatively with the American Medical Association. Finally, he proposed that each member of the Academy discuss every fee with his patient before undertaking any procedure

18 Whitman, Howard: Why Some Doctors Should Be in Jail. Collier's, /32:11, 23, 1953. 18 Truman, S. R.: Editorial, Why Some Doctors Should Be in jail. GP, 8:8, 32, 1953. 434 Fellowship of Surgeons more extensive than the usual office visit. Each patient should be offered a choice of more than one consultant whenever possible. Each physician should send a separate bill to the patient for the value of the services performed. Coming from the respected leader of the recently organized Academy of General Practice, several members of which were making their presence felt within the American Medical Associ- ation's influential committees, Truman's article was of great significance. It gave encouragement to the Regents of the Col- lege and it effectively silenced those doctors who protested that publicity should be avoided at all costs. During the 1953 Clinical Congress held in Chicago, the entire Board of Regents met with representatives of the press who were present in larger numbers than ever before. The scientific sessions of the Congress were reported by expert professional science writers. The reporters were outspoken in their praise of the relations which the Regents had developed with the press and hoped that this would serve as an example for other medical organizations. The Regents asked Fellows of the College who had taken part in the introduction of resolutions in the House of Delegates of the American Medical Association to appear before them. Those who appeared stated that they did not personally support the content of the resolutions but acted only as delegates of their respective state medical societies. Graham and other Re- gents agreed that delegates to the American Medical Associa- tion were duty bound to introduce resolutions if so directed by their state medical societies. However, some of the Regents, including Graham, indicated that the strength of an individual's belief in a principle would be an adequate reason to resign as a delegate rather than present 'a resolution to which he was opposed. Again, there were persistent promptings that representatives from the Board of Trustees of the American Medical Association and from the Board of Regents should meet and discuss ways and means by which the two organizations could co-operatively fight all unethical practices in the medical profession. Meetings were held in October and November 1953. Fellowship of Surgeons 435 It was proposed that the Board of Trustees urge the House of Delegates to support a movement to obtain legislation in the states in which laws proscribing fee-splitting did not exist. The Trustees believed they could not push this suggestion because there was little evidence that the existing laws in the 22 states had accomplished anything. As far as approaching the Internal Revenue Bureau, as the College had suggested, the Trustees objected. If this were done, every doctor in the United States would be branded as a suspect. The Trustees said that each of them individually would oppose any modification of the American Medical Association's code of ethics along the suggestions from the Iowa State Medi- cal Society. One of the optimistic Regents said that he was sure the Trustees realized the magnitude of the problem and that simply because they were meeting with Regents in an attempt to raise the standards of medical practice would deter some doctors from unethical practices. With some experience within the American Medical Association, he was fully aware of the inability of the Board of Trustees to implement a policy directly or to enforce disciplinary measures. This made it difficult for the representatives of the two groups, so different in their functions and powers, to accomplish anything. The Regents could commit the College of Surgeons to a policy; the Trustees could not speak for the American Medical Association. The Board of Regents continued to meet with science writers and other representatives of the press at successive Clinical Congresses. Questions were asked about the effect of the College program upon unethical practices. Had the Regents censured Hawley because of the U. S. News & World Report interview? How many hospitals had been disapproved because they tolerated unethical practices? What other medical organizations had joined the College in its efforts to stamp out fee- splitting? What other organizations had the power to discipline their members as did the College? Had the College suffered as the result of criticism of its publicity on fee-splitting and unnecessary surgery? The Committee on Public Relations of the Board of Regents, constituted in 1952, and the committee of the Regents appointed 436 Fellowship of Surgeons to confer with Trustees of the American Medical Association wrote the following definitions of four unethical practices: An unjustified operation is one in which either the indications were inadequate, or the procedure was one which is contrary to generally accepted surgical practice. Ghost surgery is that surgery in which the patient is not informed of, or is misled as to, the identity of the operating surgeon. Fee-splitting is the refunding of any portion of the total fee for the care of a patient to either the surgeon or referring physician. Moreover, when the surgeon or the referring physician submits a joint bill, itemized or unitemized, it shall be interpreted as fee-splitting, according to the principles stated by the Judicial Council, and approved by the House of Dele- gates of the American Medical Association in December 1952. A fee is excessive when it is greater than the patient is reasonably able to pay or higher than justified by the service rendered. The Regents forwarded these statements for guidance to the Joint Commission on Accreditation of Hospitals and were assured that the proper authority in the American Medical Association would take the same action. Employment of a medical audit to evaluate the character and results of patient care in hospitals was being supported financially by the Kellogg Foundation, and the Joint Commission on Accreditation of Hospitals was insisting that hospital staff members pledge themselves not to split the patient's fee. The Regents believed that these would be the most effective means to stop unethical practices. They were sure progress was being made mainly as the result of the publicity which the College had sought deliberately. The science writers also recognized the high standards which were being set by the scientific programs at the Clinical Con- gresses. Daily features of the Congress were the Cine Clinics at which motion picture films depicting new techniques and procedures in surgical treatment were shown. In the majority of instances the authors were present to comment and answer Fellowship of Surgeons 437 questions. These popular well-attended meetings were the result of the financial investment by the Davis & Geck company" in paying for new films made by Fellows of the College and the persistent and contagious enthusiasm of Hilger P. Jenkins, chairman of the Committee on Medical Motion Pictures. Television programs broadcast in color from a chosen teaching hospital of the city in which the Congress was held were sponsored by the Smith, Kline & French Laboratories. Opera- tions, combined with discussions and questions by a moderator and members of a panel, were televised to a meeting room. The audience could view the operations in which they were interested. This popular feature of the scientific program had replaced the hospital surgical clinics which had been the outstanding feature of the first Clinical Congress in 1910. Through the efforts of The Director, Fellows of the College were given the opportunity of participating in a group disability insurance program. The plan contained many advantageous features which otherwise they would be unable to obtain individually. This was an innovation proposed by Hawley which illustrated that there were several areas in which the College had a deep interest in the welfare of its Fellows. It was not just a disciplinary organization. On the contrary, the College could give evidence of the belief of the Regents, expressed by Newell W. Philpott in his presidential address, that a "fellowship is a companionship of good companions drawn together, bound together, and sharing together a love and admiration of their life's work."21 The Regents were anxious to inaugurate scholarships for young surgeons who showed promise in their research abilities and teaching accomplishments. The candidates were to be individuals who wished to be connected with a medical school and teaching hospital. Funds for the first scholarship award in 1954 had been provided by Charles 0. Finley in 1952. The institution in which 20 Later known as the Surgical Products Division, American Cyanamid Company. 21 Philpott, Newell W.: Our College In a Changing World. Bull. Am. Coll. Surg., 44:1, 1959. 438 Fellowship of Surgeons the candidate worked, the Regents said, must agree to provide a faculty appointment upon completion of the scholarship. Later, Finley provided money for three additional scholarships. Grants from the James S. Kemper Foundation provided three scholarships, and an additional one has been supported by funds subscribed by Fellows of the College and augmented from the general funds of the College. Thus, eight scholarship awards of $20,000 each for terms of three years have been made in the last few years. Another series of scholarships known as the Mead Johnson Awards for Graduate Training in Surgery have been established by Mead Johnson & Company. Four grants, each of $9,000 for three years, have been made. The candidate must have completed at least two years of an approved residency training in surgery or one of its specialties. He must also have exhibited an aptitude for additional extended study, but it is not necessary that the candidate be committed to a teaching or research future. Two scholarships have been made possible through the generosity and interest of Mrs. Elizabeth Miller Weicker. These grants of $4,000 each may be awarded to a foreign surgeon who desires a year of study in the United States to increase his training in a special field of interest in surgery. The College finally was fulfilling the original plans which spoke of its future activities in surgical research. The methods of accomplishment were different from those envisaged by the first Regents, who imagined research laboratories located in the College buildings. Now investments were being made in young men working in their own environments. Gradually, the Board of Regents had raised the requirements for Fellowship in the College. A policy, effective January 1, 1955, made it mandatory for medical school graduates after January 1, 1949, to possess such training in surgery or its specialties as would permit them to take the examination for certification by the appropriate American specialty board or the examination for Fellowship by the Royal College of Physicians and Surgeons of Canada. For all graduates prior to 1949, a Fellowship of Surgeons 439 residency training in surgery of at least three years duration in an institution approved for that purpose by the College was specified. In effect, these requirements for training were identical. Each year the number of applicants for Fellowship has been increasing and the quality and character of the training in surgery, voluntarily entered into by each applicant, have risen. From a total of 1,100 surgeons initiated into Fellowship in 1958, 913 had successfully passed the examinations of the American Board of Surgery or the comparable board of a surgical specialty. Franklin Martin and his colleagues would agree that the blue book directory, about which they often spoke and in which they persisted, provided a source to which laymen could turn and seek a surgeon in whose hands they could place responsibility for their lives. Undoubtedly, it is good for a large organization to have its policy-making body a target for continuing criticism. From the beginning, the majority of the Regents had been general surgeons. However, Franklin Martin had been a surgical specialist. As the surgical specialties developed, they had been represented on the Board of Regents by Squier in urology, Cradle in ophthalmology, Chipman in gynecology and others. Now there was unrest among the Board of Governors and the Fellows because it was felt that the composition of the Regents did not adequately represent the surgical specialties. There were advisory councils to the Regents in every specialty whose members had the right and privilege to appear before the Board at any time to present the problems peculiar to their specialty. Orthopedic surgery, gynecology, urology and neurological surgery were represented among the 15 elected Regents. A questionnaire prepared and circulated by Charles C. Hig- gins, a urologist and member of the Board of Governors from Cleveland, Ohio, provided data which were presented to the Board of Regents. The interest and co-operation of surgical specialists in the College were rapidly disappearing, it was said. These men were becoming more and more absorbed in the affairs of their own specialty organizations. Yet, the College was 440 Fellowship of Surgeons the one surgical body which truly represented the entire field of surgery, and its scientific programs provided the presentation and discussion of problems common to all surgical fields. It was suggested to the Regents that the advisory councils in the surgical specialties be given more direction and responsibility in the preparation of the scientific programs in their specialty. They should be consulted by the Regents instead of waiting for them to bring their problems to the Board of Regents. It should be made possible for each council to have formal meetings at the time of the Clinical Congress or oftener if they so desired. All of these suggestions were approved and adopted by the Regents. The Board of Governors then proposed that the Board of Regents be increased in number so that the surgical specialties could have greater representation upon the Board in the future. It was proposed that the total number of Regents should be increased by one each year through 1957 when there would then be 19 elected Regents. The President of the College would serve as the twentieth Regent during his year's term of office. No serious objection was raised to this proposal, and the appropriate bylaws were adopted by the Board of Regents to effect the provision. Evarts Graham had been a dynamic representative of the College. He had vigorously championed the policy that the American College of Surgeons should take the lead in presenting to the public the case against unethical practices in the medical profession. Graham was aggressive and impatient with other medical organizations which adopted the policy that it was against the best interests of the profession to "wash their dirty linen in public." He was equally antagonistic to any movement or belief which he thought tended to lower the standards of surgical care. It appeared to the Regents that if his service to the College as a Regent terminated just at the time when the College was being severely criticized for its efforts to combat unethical practices, it would be misunderstood and might well be misinterpreted as a lack of confidence in his leadership and a reversal Fellowship of Surgeons 441 of the policy of the Board of Regents. Graham was anxious to remain as a Regent and as Chairman of the Board. The nominating committee of the Board of Governors submitted his name for election as a Regent for an additional term of one year, and he remained as Chairman of the Board of Regents until Novem- ber 19, 1954. At the same time, however, there was a strong belief among the Fellows and Governors that the terms of Regents should be definitely limited. Again, charges that the Regents were too old and did not truly represent the Fellowship, that they were self-perpetuating and that younger blood was needed were repeated as they had been cyclically and undoubtedly will continue to be in the future. The Governors proposed that the bylaws state that a Regent could be elected only for three terms of three years each. The Director pointed out that it was foolish to restrict the actions of the Governors and Fellows in the future. It was quite possible, he said, that they might well desire to have an individual remain as a Regent for 12 years because of his contributions and strategic value to the College. He emphasized the fact that the Governors nominated and elected the Regents. They could easily terminate the services of a Regent as they chose; they alone controlled the nomination and the election of Regents. The position and influence of the Board of Governors in the affairs of the American College of Surgeons had rapidly risen following Arthur Allen's proposal to increase the part it played in the affairs of the organization. CHAPTER 14

T WAS WITH expressed misgivings that Evarts Graham reluc- I tantly relinquished the chairmanship of the Board of Re- gents. For 13 years he had unselfishly devoted his energy to the affairs of the College. Graham had become identified in the minds of the public and the profession as the spokesman who dictated policies for the most influential surgical organization in the United States. He was not sure that the younger men among the Regents could carry on. After he became a Regent, he realized that experience and age were valuable assets to the College. Forty years had passed since the College was formed from the imaginative dreams of Franklin Martin. The population of the United States had increased by two-thirds. Life expectancy of both sexes had risen from 50.3 to 69.3 years. The death rate had decreased from 13.8 per thousand to 9.2, and employment, security and health of the aged were posing problems for the medical profession. A new group of specialists, the geriatricians, had arisen to meet them. The citizens of the United States owned 76 per cent of the world's automobiles, and the accident rate had climbed to 81.6 per 100,000. The Korean war, termed a "police action" by President Truman, was terminated by the newly elected Presi- dent Eisenhower, military hero of World War II and the over- whelming popular choice of the people. The North Atlantic Treaty Organization, of which Eisenhower was the first Supreme Commander, had been formed successfully to protect the western nations from the threat of their former ally, the Soviet Union. Following various atomic bomb experiments, an even more deadly hydrogen bomb had been built and tested successfully. The Soviet Union soon announced that it too, could explode Fellowship of Surgeons 443 a hydrogen bomb, and a stalemate was reached in the race to destroy the world. In 1913, only 3,679 students were graduated after completing medical school courses. By 1914, the number of medical schools had been reduced from 157 to 108. Of this total, only 68 were designated as Class A. In 1955, there were 76 approved medical schools in the United States which graduated 6,845 students with the degree of doctor of medicine. On April 1, 1953, President Eisenhower signed the bill which created the Department of Health, Education and Welfare. Oveta Culp Hobby was appointed to the Cabinet as the first Secretary of this important department which was to look after the well-being of all the people. Creation of the Department of Health, Education and Welfare strengthened a philosophy, engendered in the preceding 20 years, which looked to the Federal Government to shelter its citizens from birth to the grave. A program was proposed which urged the formation of a $25,000,000 fund for establishment of a limited Federal reinsur- ance service encouraging private and nonprofit health insurance organizations to offer broader health protection to more families. However, it was rejected by the House of Represent- atives. Other recommendations included increased aid to states and local communities to improve health and welfare services, construct hospitals for the chronically ill and expand programs for the construction of clinics. In hundreds of communities, hospitals were to be built with Federal Government subsidy. In some communities, these hospitals significantly improved the quality of medical care. Well- trained doctors in surgery and the surgical specialties were attracted to those areas and brought with them the best in modern medicine. In many communities, however, the effect was the opposite. Provided with a lavishly equipped, modern hospital, members of the local medical profession were encouraged to use the facilities. Soon surgical operations were performed by doctors incompetent to undertake the complicated procedures because they had not had the necessary years of voluntarily acquired 444 Fellowship of Surgeons special training. The social planners had sought quantity in medical care and were to sacrifice quality. The Regents were seriously disturbed over another aspect of medical care. This was the rapidly spreading effort to extend the benefits of medical care by providing insurance protection against the costs of that care. The growth of voluntary health insurance plans in the face of threatened governmental control was becoming phenomenal. Again, insurance programs were increasing the quantity of medical care but without any regard whatever for quality. These plans were compensating just as freely for poor medical care as for good and, in many instances, were paying far too much for inadequate care. In the past, many surgical operations were performed without charge because the patients had no money. Every insured patient had now become a paying patient, and the result was an increasing number of surgical operations performed by inadequately trained doctors. The Regents recognized that two factors were responsible for the situation. One was the doctor whose conscience did not restrain him from performing surgical operations for which he had received no training. The other factor involved the patient who encouraged the doctor to operate. It was becoming more and more apparent that the average patient believed that a license to practice medicine and surgery carried with it a certificate of competence in every facet of medical care. The Regents had evidence that over half the surgical operations in the United States were being performed by doctors with insufficient surgical training or none at all. Patients, with intelligent judgment in other matters, were cheer- fully hopping up on operating tables and allowing a medical school graduate with one year of training in a rotating internship to peer and search aimlessly within their abdominal and other body cavities. Though often urged to lend the support of the American College of Surgeons to influence state and federal legislation, the Regents had steadfastly refused. Gradually, they had committed the College to the policy of reinforcing efforts to elevate Fellowship of Surgeons 445 the standards of surgical training and treatment of the surgical patient by informing and educating the public. The beginnings of such efforts had been regarded as revolutionary. Now it appeared that they should be continued persistently though perhaps less dramatically. I. S. Ravdin, John Rhea Barton Professor and Chairman of the Department of Surgery at the University of Pennsylvania Medical School, the oldest in the United States, was chosen by the Regents as their Chairman to succeed Graham. Thus, Ravdin became the fifth distinguished surgeon whose individual abilities, talents and personal characteristics would leave their impression upon the College. Ravdin was born in Evansville, Indiana. Like all Hoosiers, he was inordinately proud of his state and its traditions. There was some reason for bragging about the accomplishments of Indiana; the center of population of the United States was in Bloomington, and George Ade and Booth Tarkington were Indianians. Ravdin attended Indiana University and later joined Black Jack Pershing's forces which were campaigning rather unsuccessfully against Villa, the Mexican bandit and murderer. Orgin- ally, Ravdin planned to attend Harvard Medical School and was accepted by that institution. However, through the influence of James B. Herrick, a well-known Chicago physician, and by chance he was diverted from registering there. Herrick, a friend of his father's and a contemporary of Franklin Martin, strongly recommended Rush Medical College or the University of Pennsylvania. Ravdin chose the latter. The Regents were well aware of Ravdin's boundless energies, his loyalties and integrity. In his experimental surgical laboratory he had made valuable contributions to the advancement of surgical knowledge. He had served with distinction in the China-Burma Theater in World War II and became the commanding general of the hospital there which had been organized at the University of Pennsylvania. His abilities, personality and reputation combined to make him the key medical figure in the military operations 446 Fellowship of Surgeons of that area. The Regents looked forward with hope to the rule of a persuasive rather than a dictatorial chairman under whom discussion and debate could bring about well-considered decisions. Immediately, Hawley and Ravdin implemented a plan which The Director had been developing for the administrative offices of the College. A great increase in the activities of the College had made it necessary to departmentalize the work to provide prompt and acceptable service to the Fellows. Meetings of the Board of Regents were changed from lengthy, uncontrolled discursive sessions to efficiently managed affairs. The Board could give careful consideration to important problems after preliminary hearings and investigation were conducted by the staff and committees of the Regents. Delineating responsibility provided the additional advantage of stimulating the best efforts of the entire staff. The Executive Department was organized and headed by The Director and an Assistant Director. Other phases of activity were assigned to the Department of Organization and Assem- bly, the Department of Business and Finance, the Department of Fellowship and the Department of Professional Services and Accreditation. Each group, under the direction of an Assistant Director, could bring problems to a liaison committee of the Board of Regents. The conclusions and recommendations of each committee would then be placed before the entire Board of Regents for appropriate action. Immediately, it became apparent that every facet of the work of the College was being given detailed attention by the staff and the department director, The Director, the committees of the Regents and, finally, the Board of Regents. This was a great step toward insuring future permanency, solidarity and efficiency in the activities of the College. Through the years the Committee on Cancer of the American College of Surgeons had quietly and persistently continued its work in the education of the public. Cancer clinics in general hospitals had resulted in more efficient study and treatment Fellowship of Surgeons 447 of patients, improved records, systematic follow-up examinations of patients and education of doctors and laymen alike. By 1955, a total of 693 cancer clinics were approved by the College. Continued approval depended upon biannual surveys and inspections. Descriptions of cancer programs for general hospitals were written, revised and consolidated into a manual for guidance. The College had worked with the American Cancer Society to develop cancer detection centers. Standards were established and the same relation applied to these centers as to cancer clinics. College surveyors evaluated the facilities at the expense of the American Cancer Society. In the opinion of the Board of Regents, it was difficult to assess the value of the centers and impossible to standardize the work. For these reasons, the College in 1953 discontinued the work of accrediting detection centers. The work of the Committee on Cancer was supported in the beginning wholly by the funds of the American College of Surgeons. In 1938, the National Cancer Institute granted financial aid for the work of the Committee. As the activities of the cancer survey program increased, the cost rose rapidly. In 1955, expenses of the program were born by the National Cancer Institute to the extent of 50 per cent of the annual budget and 25 per cent each by the American Cancer Society and the American College of Surgeons. The estimated budget for the work of the Committee on Cancer of the College for the year 1955 was approximately $95,000. A great deal had been accomplished since 1912 when Thomas S. Cullen advocated an organized program of education on cancer for the medical profession and for the public. Progress had been rapid since the first public meeting on the subject had been held during the Clinical Congress of Surgeons.

Before Franklin Martin's death, the American College of Sur- geons had stirred up a hornet's nest when the Board of Regents issued a statement concerning medical service plans. The House of Delegates of the American Medical Association considered 448 Fellowship of Surgeons this problem its prerogative. Under the chairmanship of Irvin Abell, the Board of Regents accepted that position and remained silent. More and more, however, the position of the third party interested in the patient and so-called "corporate" medicine became subjects of discussion and disagreement among doctors. In December 1954, the Principles of Medical Ethics of the American Medical Association contained the statement: Free choice of physician is defined as that degree of freedom in choosing a physician which can be exercised under usual conditions of employment between patients and physicians. The interjection of a third party who has a valid interest, or who intervenes between the physician and the patient does not per se cause a contract to be unethical. A third party has a valid interest when, by law or volition, the third party assumes legal responsibility and provides for the cost of medical care and indemnity for occupational disability.1 Three years later this section of the Principles of Medical Ethics had disappeared. However, the Principles did state that: A physician should not dispose of his services under terms or conditions which tend to interfere with or impair the free and complete exercise of his medical judgment and skill or tend to cause a deterioration of the quality of medical care. Frequent altercations were developing among certain groups. On the one side, the medical profession was represented by the American Medical Association. Presenting another view were industry, labor unions and insurance groups. A third side was represented by hospitals, with their radiologists, anesthesiologists and laboratory personnel who were remunerated by the hospitals. Surgeons who were paid by medical schools and hospitals for their services to patients and for their teaching responsibilities were also implicated. A case in point involved the United Mine Workers Welfare and Retirement Fund, for many years directed and administered 1 Free Choice of Physician. Principles of Medical Ethics of the American Medical Association, Chapter 7, Section 4, December 1954. Fellowship of Surgeons 449 by Dr. Warren F. Draper without interference from the labor union leaders. The medical program of this fund originally had been a fee-for-service and free-choice-of-physician plan. Soon it was noticed that there was an unduly high hospital admission rate, appreciably above the average throughout the United States and the experience of the Blue Cross insurance plan. A considerable number of unnecessary or unjustifiable surgical operations also appeared. Draper adopted the policy that hospitalization for patients under the Welfare Fund's medical program could be obtained only after a consultation had been requested by the family doctor. Immediately, hospital admission rates and the number of operations dropped as much as 50 per cent in some areas of the country. A storm of protest from local doctors reached county and state medical societies. The Pennsylvania State Medical So- ciety entered into an agreement to establish committees to review doctors' qualifications to co-operate with the Welfare Fund. The Society abrogated this agreement after a year's experience. Draper then limited surgical operations in mine workers' hospitals to those doctors certified by one of the boards of surgery or to Fellows of the American College of Surgeons. Again, a storm of protest was raised in county and state medical societies. In some areas, doctors employed on a full-time basis by hospitals operated by the Welfare Fund were refused membership in the local medical societies. The Board of Regents recorded its opposition to any similar action which might be taken by local credentials committees passing on the qualifications of applicants for Fellowship. The Board's opinion was that any doctor had the right to choose for himself the method of remuneration for his professional services, providing it was morally and professionally ethical. The Regents were quite aware of the extraordinary development of insurance and welfare plans. In 1952, approximately 92 million citizens were protected by hospital insurance. By 1957, this figure had risen to 123 million. During the same period the number of individuals covered by insurance for surgical fees 450 Fellowship of Surgeons rose from 73 million to 109 million. The total medical bill for the United States in 1957 was 15 billion dollars. In all of the insurance plans and welfare funds, a third party had been insinuated between the patient and his doctor. The Regents became more and more concerned with the payment of surgical benefits directly to the surgeon instead of to the patient. They were also alarmed by the increasing practice of prorating the surgical fee among doctors engaged in the care of the patient and stated that such a practice was unethical. However, the Regents were faced with the realization that the situation already existed, and prohibiting the Fellows from engaging in it temporarily was both unrealistic and unjust. The intent of the Regents, clearly expressed, was to set forth principles of application which would minimize the danger of employment of proration as inducement in the referral of patients.2 This hope was not realized. Included was a statement that the principles enunciated did not represent the ideals of the College but the action was taken in view of a situation which could not be altered at that moment. The policy of the Board of Regents was based upon these principles: 1. Every physician contributing to the care and treatment of a patient is entitled to just and reasonable compensation. 2. The compensation of each participating physician must be commensurate with the service he has rendered, and must not be based upon the compensation of any other participating physician. 3. No surgical fee may ethically be divided for the purpose of compensating two or more participating physicians. 4. Surgical care and treatment include preoperative study and preparation, the operation, and postoperative management. 5. The training of the surgeon makes him more competent to supervise postoperative care and treatment than another not qualified in this field; and the surgeon must not relinquish this responsibility except in those rare emergencies in which it is impossible or manifestly impractical for him to undertake it.

2 Regents Adopt Principles Permitting Proration of Blue Shield Fee Between Surgeon and Assistant. Bull. Am. Coll. Surg., 40:3, 174, 1955. Fellowship of Surgeons 451 When it is necessary to divide the total responsibility for surgical care, compensation for each part may be fixed with relation to the professional responsibility involved in each. No one seriously doubted that proration of surgical benefits grew out of the sincere desire to extend the area of protection for the insured patient without increasing the cost of insurance. Arguments that patients were spared multiple billing and that the insurance companies objected to the necessarily complicated bookkeeping procedures were not valid in the minds of a few Regents. In the beginning, the surgical insurance protection of the patient was limited to the benefit paid to the surgeon. Many surgeons employed regular assistants; others operated in hospitals with adequately trained surgical house staffs. Anesthesia service was provided by the hospital and covered by the patient's hospital insurance. So, to a large degree, the surgical insurance benefit covered the cost of the professional services. However, many hospitals did not have interns and residents. In such circumstances, the surgical benefit did not provide for payment of the assistant, who in the majority of instances was also the referring physician and could not be paid by the surgeon according to repeated rulings of the Judicial Council of the American Medical Association. Therefore, there was no way by which a referring physician could be compensated from insurance benefits for any service to his surgical patient. Some insurance plans provided compensation for consultation in complicated cases, but the referring physician had to look to his patient directly for his fee. The introduction of a third party, the insurance company, with an assured fee to the surgeon, made referring doctors un- happy and highly desirous of protecting what they believed were their rights in the patient's insurance benefits. It was also said that patients were dissatisfied when their physician later presented his bill because they believed that the insurance covered all professional fees. To meet these objections, some insurance companies began to pay the referring physician for assistance at the operation and 452 Fellowship of Surgeons for postoperative care from the benefit provided for the surgeon. As Hawley pointed out, such a practice is no different from that of the surgeon paying the referring physician from his fee, since the money paid by the insurance company comes from the surgeon's fee. Both practices are unethical. The primary principle governing the prohibition of financial dealings between the surgeon and the referring physician is usually ignored. It is not an arbitrarily chosen rule or precept supported by an outmoded economic tradition. The purpose is to eliminate inducements in the selection of doctors; to prevent any consideration, other than the quality of professional care, from influencing the physician in the selection of a surgeon to operate upon his patient. Based upon facts in their possession, the Regents were of the opinion that proration of insurance benefits was encouraging bad surgery and unethical practices. The privilege of assisting at an operation, when other surgical assistants were readily available, and supervising postoperative care for a part of the insurance benefit had become inducements. After careful study and approval by the actuaries of two large life insurance companies, Hawley made a suggestion. He proposed that insurance carriers could pay for the assistance of the referring physician either by raising the average benefit, which would raise the cost of the insurance premium, or retain the same benefit and lower the amount paid to the surgeon. Hawley pointed out that the Regents were not interested in how much the insurance plan paid the surgeon. They were concerned only with the question of how it was paid. The position of the American College of Surgeons was summarized simply. The insurance carrier should determine what professional services it would cover. It should provide a separate schedule of benefits, without one being a deduction or proration of any other benefit, and pay individually each physician who contributes to the care and treatment of the patient. The principles concerning medical care insurance plans continued to be a subject for discussion between representative Fellowship of Surgeons 453 Trustees of the American Medical Association and Regents of the College as recently as April 23, 1959. Ravdin had been successful, with a few Trustees, in reactivating informal conferences between the Trustees and Regents in the hope of accomplishing harmony. Similar meetings had been held with authorized representatives of the American Academy of General Practice. The groups agreed that the entire question of how to prorate a surgical benefit ethically could be solved simply. This could be done if the medical profession insisted that benefits be paid to the insured and that every doctor look to his patient for the payment of his fee for services. However, it was also recognized by everyone participating in the discussions that a resolution stating that principle would never be passed by the House of Delegates of the American Medical Association. Many doctors were apprehensive over the growing tendency for governing board of hospitals to grant surgical privileges only to men qualified by training to be a surgeon. There were physicians who had not chosen to make the necessary sacrifices to be trained as a surgeon and yet wished to be so recognized in their communities. Also, there were sincere and conscientious doctors who had no desire to be surgeons but who found it necessary in their small community to perform what they termed "minor" surgery. The Regents of the College would not recognize this term because they were well aware of the trage- dies which could easily ensue if any surgical operation was considered a trivial matter. It was also a fact that no doctor would consider any surgical procedure "minor" if he were the patient. In all the discussions, it was agreed that professors of surgery in medical schools were responsible for teaching students the principles of the proper immediate care of the injured patient and of other types of surgical emergency situations. But, the Regents insisted that medical students should also be taught the principles of definitive surgical treatment which, in view of better transportation, unproved hospital facilities and well- trained surgeons, did not require immediate implementation. 454 Fellowship of Surgeons The damage which could be inflicted by poor surgical treatment was quite clear in the minds of all of the Regents. It was not so well recognized, the Regents believed, by those who had received little or no surgical training and sought surgical privileges in accredited hospitals simply because they had a state license to practice medicine. The Regents could not agree that the character and extent of those surgical privileges should be determined by the individual's colleagues on the hospital staff. This question of surgical privileges was discussed on more than one occasion by the Regents and representatives of the American Academy of General Practice. Here again, this medical organization was a confederation of state chapters which were autonomous. Its Trustees could hope only to influence policy in each chapter; they could not establish a national policy. The Regents believed that many of the problems concerning unethical practices could be solved by properly educating medical students about their existence. In an effort to carry out this belief, the Board voted to invite a student representative from each approved medical school to attend the Clinical Congress. The method of choice of the student would be the prerogative of the Dean of the medical school. The College would pay the transportation cost and a per diem for each student from approximately one-third of the medical schools in the United States and Canada each year. This program was inaugurated in 1956 and was an immediate success. The students are assigned to a group of Fellows of the College who act as their hosts during the week. Each student has the opportunity to attend the various scientific sessions. Luncheon and dinner discussion groups are arranged and participated in by surgeons whom the students meet informally. It is realized that only a small number of the students chosen to attend will become surgeons. However, the purpose is to help medical students learn about the efforts which one large surgical organization makes to aid its Fellows in continuing their education to be a surgeon. The College has required of the Fellowship of Surgeons 455 student guest only that he report his experiences to his class- mates. The differences existing between the American College of Surgeons and the International College of Surgeons, based upon the existence of the International Board of Surgery, were rekindled in 1958. A series of letters, initiated by Edward L. Compere, the newly elected president of the United States Sec- tion of the International College of Surgeons, passed between him and I. S. Ravdin, Chairman of the Board of Regents of the College. It was then learned that the Executive Council of the International College had voted unanimously on January 26, 1952, not to undertake legal action against the American College of Surgeons. In a statement in which he set the facts in chronological order, Ravdin emphasized that Norman M. Littell did threaten legal action against the American College of Surgeons on three occasions prior to the action of the Executive Counci1. 8 Littell had represented himself as the General Counsel of the Interna- tional College of Surgeons and stated that he was acting with the authority of that organization. The American College of Surgeons had never been informed of any change in that plan of action. The resolution adopted by the Executive Council of the International College contained the statement that "at no time did the International College of Surgeons sue nor would it tolerate any such action against any medical organization." According to Compere, the International Board of Surgery was abolished shortly after January 26, 1952. The word "Board" was removed from all certificates of membership or fellowship issued thereafter by the International College of Surgeons. In his letter, however, Compere did not supply the complete text of the resolution adopted by the Executive Council of the International College of Surgeons. It contained several paragraphs which followed in context the practices of the past The chronology of events is authoritatively given in a pamphlet entitled "A Statement by the Chairman of the Board of Regents," written by I. S. Ravdin and printed by the American College of Surgeons in April 1959. 456 Fellowship of Surgeons history of the medical profession. The usual custom in the discussion of principles which might elevate the standards of medical care or newly discovered methods was to resort to personal attacks. So, in this instance, attacks upon Evarts Graham and Paul Hawley helped to confuse the fundamental issue which concerned the standards for the qualification of surgeons. Among other paragraphs, the resolution contained the following:4

WHEREAS, it appears that a small group of malcontents and propagandists in the American College of Surgeons, led by Dr. Paul R. Hawley, a former member of the International College of Surgeons, are obviously creating discords by misrepresenta- tions and intimidations; and WHEREAS, Dr. Hawley ( apparently a self-appointed apostle) has circularized a Resolution over his signature purported to be by the Board of Regents of the American College of Surgeons criticizing the actions of the International College of Surgeons; and WHEREAS, the American Medical Association appointed such a Committee as did the International College of Surgeons, but Dr. Hawley's group refused to co-operate; BE rr THEREFORE RESOLVED by the Executive Council of the United States Chapter of the International College of Surgeons now in session to: 1. Exert every effort to arbitrate this matter; and 2. Request that the American College of Surgeons rescind the nefarious Resolution which passed on December 3, 1951 and 3. Request that those members who have been caused to resign from the United States Chapter of the International College of Surgeons because of intimidations by Dr. Hawley be advised that there has been a misunderstanding and that they be urged to continue their membership in the United States Chapter of the International College of Surgeons; and 4. Assure all concerned that court procedures were never contemplated by the International College of Surgeons and

4 The entire text of the resolution of the Executive Council of the International College of Surgeons is contained in Ravdin's statement Fellowship of Surgeons 457 that such would never be tolerated by the International Col- lege of Surgeons under any circumstances; and. . . . The Board of Regents of the American College of Surgeons was unaware of the existence of this resolution until July 1957. At that time a copy of a letter, addressed "To All Members and Friends" and signed by Dr. E. N. C. McAmmond, secretary of the Canadian Chapter of the International College of Surgeons, was forwarded to the American College of Surgeons by an individual who had received it. The Board of Regents did not rescind the action adopting the resolution of December 3, 1951, protesting the establishment of certifying boards of surgery which might tend to lower the standards of surgical training. It had been stated by the Inter- national College of Surgeons that prior to the resolution passed by the Board of Regents, the American Board of Surgery had not criticized its actions in creating the International Board of Surgery and giving examinations leading to this certificate. The implication appeared to be: why should the American College of Surgeons concern itself? It is true that the Board of Regents of the American College of Surgeons initiated the action which ultimately ended in the discontinuance of the International Board of Surgery. Other surgical organizations followed and supported that action. Immediately prior to the opening of the Compere-Ravdin correspondence, The Director of the American College of Sur- geons called the attention of the Board of Regents to the many requests received for information about the "American Board of Abdominal Surgery." The Director was instructed by the Regents to furnish the Fellows with all available information about the proposed new board!' In spite of efforts to learn the origin and sponsors of the organization, little had been discovered about its purposes. To guide the Fellows of the College, they were reminded that 19 American specialty boards had been organized under the aegis 6 American Board of Abdominal Surgery. Bull. Am. Coll. Surg., 43:5, 244, 1958. 458 Fellowship of Surgeons of the Advisory Board for Medical Specialties. Ten of these boards were in surgery and the surgical specialties. Each board had gained an official status in the medical profession through sponsorship by recognized national societies in a particular specialty of medicine and the corresponding section of the scientific division of the American Medical Association. In addition, each board had been elected to membership in the Advisory Board for Medical Specialties and had been approved by the Council on Medical Education and Hospitals of the American Medical Association. Again, the Regents wished to emphasize to the Fellows that any organization which called itself a "board" and which did not meet the existing requirements could not obtain listings for the holders of its certificate in the Directory of Medical Specialists or the Directory of the American Medical Association. Neither would membership in such an organization be indicated in the official publications of the American College of Surgeons. At the time the letter announcing the American Board of Abdominal Surgery was sent to doctors, neither the Advisory Board for Medical Specialties, the Council on Medical Education and Hospitals of the American Medical Association nor the American College of Surgeons had been requested to give support to such a qualifying board. A campaign persisted, however, to recruit a founders' group for the American Board of Abdominal Surgery. Several representative surgical organizations expressed their disapproval, but the movement continued. There were some implications that the approval of the Advisory Board for Medical Specialties was assured and would be announced. Upon investigation, The Director informed the Board of Re- gents that in his opinion such an optimistic view was unjustified. It was quite certain that the requirement of sponsorship by recognized national surgical societies had not been met. Even such sponsorship, were it obtained, did not assure approval by the Advisory Board for Medical Specialties, the membership of which is made up of representatives of the established boards of certification. Fellowship of Surgeons 459 Just as it had done in the case of the International Board of Surgery, the Board of Regents advised Fellows of the College to await approval of any newly established board of examination before lending their names to its support. Only in this way could the Fellows be sure that the standards to be adopted by any proposed board of certification would be equal to those already existing. The obvious question arose in the minds of many doctors. Had the sponsors of the proposed American Board of Abdominal Surgery failed to be certified by existing examining boards in surgery and its specialties? Had they failed to gain Fellowship in the American College of Surgeons? It appeared certain that the struggle to maintain and improve the high standards of care for surgical patients which had been going on for 45 years could never be slackened. Human nature would dictate the necessity of eternal vigilance. The Regents of the American College of Surgeons had long recognized that education of surgeons must be accompanied by education of the public. This once revolutionary idea had gradually been accepted by the medical profession. Now it seemed appropriate to attempt to inform the laity about the education and training required for a medical school graduate to become a surgeon. The public could be made aware of the training and experience necessary for the surgeon to pass the rigid tests of knowledge and abilities demanded by qualifying boards and the equally rigid requirements of honesty, integrity and ethics in practice demanded of candidates for Fellowship in the Ameri- can College of Surgeons. Particularly, it seemed important to emphasize that the years of training and practical experience in surgery beyond a year of hospital internship immediately after medical school graduation were not legal requirements to practice surgery in any state. These were years of hard work and sacrifice entered into voluntarily by young doctors who aspired to become surgeons. The law gave any doctor licensed by his state the right to perform a surgical operation. How could a layman learn to 460 Fellowship of Surgeons choose a surgeon unless he was informed in an interesting manner just how a doctor acquired the training needed to become a surgeon to whom he would entrust his life? So, a motion picture entitled HANDS WE TRUST was filmed at the direction of the College. The film, available for showing to any lay or professional group without expense, portrays the 11 years of education necessary to become a Fellow of the Ameri- can College of Surgeons. As tensions in the world of politics and international relations increased, many members of the medical profession sought means by which they might contribute to the peace. During an informal conversation among distinguished foreign guests of the College at the Clinical Congress held in Chicago in 1955, the thought was expressed that perhaps doctors should attempt to accomplish goals within their own profession. Such goals might then grow into strong influences in negotiations for peaceful solutions of the world's problems. It was the consensus that international surgical societies made up of individual members did not fulfill the important need for elevation of the average standards of surgery throughout the world. Perhaps, it was suggested, this could be accomplished only through a co-operative effort by national societies of the various countries. Standards for the care of surgical patients in each country are elevated by societies imposing rigid requirements for membership. The suggestion was made that an international confederation of surgical colleges and societies would accomplish throughout the world what each member society attempts in its own country. Membership would be limited to national societies having high standards. Following this informal discussion, the Council of the Royal College of Surgeons of England invited the American College of Surgeons to send representatives to London to pursue the proposa1.6 Broad principles of organization and purpose were

6 The Regents appointed Drs. I. S. Ravdin, Warren H. Cole, Loyal Davis and Paul R. Hawley as their representatives. This group went to London for a meeting at the Royal College of Surgeons in April 1956. Fellowship of Surgeons 461 agreed upon, and the Council of the Royal College and the Board of Regents approved the project in principle. In May 1957, representatives of selected national surgical societies were invited to meet in London. At this meeting, the American College of Surgeons was represented by Ravdin and Hawley. The proposal was accepted unanimously, and a temporary organization immediately effected. Sir Harry Platt of England was elected president pro tempore. Mr. Kennedy Cassels, secretary of the Royal College of Surgeons of England, was appointed executive secretary. It was agreed that the Council of the Federation would meet during the sectional meeting of the American College of Surgeons in Stockholm in July 1958 to effect a permanent organization. At the meeting in Stockholm, the Council adopted a constitution which provided requirements for membership in the new organization, to be called the International Federation of Surgical Colleges and Societies. Financial support was provided by a per capita tax upon each member society. An Executive Committee to conduct business between meetings of the entire Council was created.? It was agreed that new members of the Federation would be admitted only upon application which would be approved by the Council. Several applications which had been received im-

7 At the Council meeting of the International Federation of Surgical Colleges and Societies held in Stockholm on July 4, 1958, the following surgeons represented their member societies: Sir Harry Platt, president pro tern, Royal College of Physicians and Surgeons of Canada (by proxy); Professor J. -L. Lortat- Jacob, Academie de Chirurgie; Dr. I. S. Ravdin, American College of Surgeons; Professor E. Dahl-Iversen, Collegium Regium Chirurgorum Universitatum Daniae; Professor J. F. Nuboer, Nederlandse Vereniging voor Heelkunde; Professor Carl Semb, Nordisk Kirurgisk Forening; Mr. Ivan Jose, Royal Australasian College of Surgeons; Sir James Paterson Ross, Royal College of Surgeons of England; Mr. Frederick Gill, Royal College of Surgeons in Ireland; Dr. A. L. Goodall, Royal Faculty of Physicians and Surgeons of Glasgow; and Dr. Philip Sandblom, Swedish Surgical Society. Professor A. M. Dogliotti, Societa Italiana di Chirurgia, was lin- able to be present but cabled his proxy to I. S. Ravdin. Sir Harry Platt was elected president. Dr. I. S. Ravdin and Prof. E. Dahl- Iversen were elected vice-presidents, and Mr. Kennedy Cassels was appointed executive secretary. In addition to the officers, the representatives of the Neder- landse Vereniging voor Heelkunde, Academie de Chirurgie, Swedish Surgical So- ciety, Nordisk Kirurgisk Forening, Royal Australasian College of Surgeons and the Societe Belge de Chirurgie were elected to the Executive Committee. 462 Fellowship of Surgeons mediately upon organization of the Federation were discussed and action deferred until further investigation could be made of the applicants' standards of membership. Each country would be allowed only one vote in the Council. This would make it mandatory for the several societies in one country to agree upon one representative on the Council. A program for the Federation was discussed, and several projects of an international nature were referred to the Council for consideration. As discussed in the beginning, the prime objective was to help in elevating the standards of surgical treatment for patients and the training and education of surgeons throughout the world. Contributions to this effort could be made by having the Federation sponsor the dispatch of surgical teams into countries backward in medical and health care; by having available similar teams which could be sent quickly to critical areas which sporadically appeared over the world. The care of the injured in the Hungarian revolt was suggested as an excellent example of a situation in which the Federation could supply aid in a humanitarian as well as an educational cause. It was apparent that the quality of the planned activities of the Federation was indicated by the stature of the members of the Council as surgeons and that future plans of the organization would develop more completely the objectives of the Federation. Thus 46 years have passed since the imaginative dream of one man proposed that surgeons in the United States and Canada band together to continue their surgical education and contribute to the elevation of the standards of care to the surgical patient. Opposition, criticism, jealousy, vilification and actions bordering upon dishonesty, if not actually so, combined on many occasions to threaten the existence of the American College of Surgeons. The steadfast determination and enthusiastic energy of Franklin H. Martin, supported loyally by a relatively small group of dedicated surgeons, resulted in one of the most significant and important contributions to the care of patients in the history of medicine. APPENDIX Chapter 1

1. In his Joy of Living, Franklin Martin states that the meeting in his home with the four young doctors to discuss a new surgical journal occurred on a December Sunday evening. Dr. William R. Cubbins, the only living member of the group, says that he is sure this occurred in September because he remembers vividly how pleasant and lovely the evening was as the young men walked home. 2. Year after year, John B. Murphy's name was proposed to the members of The Chicago South-Side Medico-Social Society by Franklin Martin or one of his other supporters. Each time the ballots were about evenly divided for and against his election as a member. In 1932, Murphy had been dead 16 years. It was the custom for each member to be the president of the So- ciety in turn. That year it was Arthur Dean Bevan's third occupancy of the presidential chair and as was the custom, he gave a presidential address. His speech dealt with the surgeons who had been the Pro- fessor of Surgery at Rush Medical College. Murphy was numbered among Brainard, Gunn, and Senn. Bevan's conclusion was that Murphy was the greatest surgeon of all. Bevan admitted that he had always voted against Murphy's admission to the Society though he recognized his great surgical and teaching abilities. The discussion which followed lasted until after midnight and, finally, Martin proposed that a vote be taken to see if Murphy would finally be elected to membership. The tally of the ballots was as it had been for the preceding 35 years. 3. Frank Billings, a cousin of C. K. G. Billings, was a graduate of the Chicago Medical College. He became a loyal and vigorous supporter of Rush Medical College. Billings gained a large practice in internal medicine in Chicago among socially prominent and influential families. His influence in medical politics was great and his tall, bulky figure and booming voice gave more weight to his words than they actually contained. Billings' personality and aggressiveness inevitably 484 Fellowship of Surgeons led to a clash between him and Martin, but within the confines of the meetings of the social-scientific club, Doering kept the peace. Lewis L. McArthur had been an intern at the Cook County Hos- pital, serving as John B. Murphy's junior. He became a respected surgeon, opposite in temperament to Billings, but a close colleague. Quiet, small and pudgy in appearance, he gained a national reputation for his contributions to the surgery of the biliary tract. He was adept at conciliating both Martin's and Billings' followers. Arthur Dean Bevan became a surgeon through his training in anatomy and shared equal prominence with Billings on the faculty of the Rush Medical College. He became Co-Chairman of the Depart- ment of Surgery with Murphy, upon the latter's insistence, and succeeded to the single occupancy of the post when Murphy became Professor at Northwestern University. Pompous in dress and speech, he contributed significantly to the field of medical education and was the first Chairman of the Council on Medical Education of the Ameri- can Medical Association. James B. Herrick was a skilled, respected internist whose preliminary education included a college degree. Kind, soft-spoken, he was judicious and in his later years younger physicians often sought him as a consultant. Chapter 2

1. There are no exact details available concerning the expense of the first clinical meeting of surgeons, sponsored by Surgery, Gyne- cology & Obstetrics. The entire financial cost of approximately $2,500 was borne by the Surgical Publishing Company. There were 930 physicians and surgeons registered at the headquarters, and it was estimated that 300 others attended but did not register. One out of every 10 doctors invited came to the meeting. The third meeting held in New York City attracted 2,700 registered doctors who paid $12,905 into the treasury. For the first time, scientific and commercial exhibits were introduced into the Congress which yielded an income of $2,215. The disbursements totaled $15,166.50 and the income $15,120.00. A break-even point had been reached. The Treasurer_ , Allen Kanavel, presented reports for the Philadelphia and Chicago meetings which were recorded in the minutes. In 1913, a certified public accountant's report was submitted by the Treasurer covering the expenses of the New York meeting. From that time on, separate accounts of the Clinical Congress expenses and the American College of Surgeons were prepared until May 29, 1935, when it was absorbed as part of the College's budget. 2. The Executive Committee of the Congress appointed a Com- mittee on Arrangements for the Philadelphia meeting, which consisted of: John G. Clark, Chairman Charles H. Frazier John B. Deaver John H. Gibbon John B. Roberts Robert G. LeConte William B. Van Lennep William L. Rodman J. Montgomery Baldy George E. de Schweinitz Edward Martin Edward P. Davis E. E. Montgomery Franklin H. Martin Barton Cooke Hirst 3. STATEMENT OF THE SECRETARY, BUSINESS MEETING, SECOND CLINICAL CONGRESS, PHILADELPHIA, NOVEMBER 13, 1911 466 Fellowship of Surgeons Gentlemen, I wish to make clear if I can, the relationship of Sur- gery, Gynecology and Obstetrics to this Congress. I do this because there has been some misinformation or misunderstanding on the part of some subscribers to Surgery, Gynecology and Obstetrics and I think this explanation will clarify the doubtful points. Surgery, Gynecology and Obstetrics was established by a coterie of Chicago surgeons for the purpose of filling a want in surgical literature and they agreed among themselves to put up as much as $50,000 if it were necessary, to make the Journal a Surgical Journal worthy of the name. We have spent of that sum to date, almost $40,000, and with some little indebtedness that we necessarily must expect in a printing business because of bills not being paid for two or three months as the Journal is in process of making, we probably have spent $45,000. Last year Surgery, Gynecology and Obstetrics, in line with the ideals we bad, conceived the idea of calling together men in Chicago for the purpose of witnessing clinics. We sent out invitations, as you all know, and to our amazement thirteen to fifteen hundred men responded to those invitations; and the clinicians of Chicago got busy and entertained these men. The two weeks' clinics were so successful that these men got together and asked that we make this organization permanent They adopted the simplest kind of a constitution and elected officers for the purpose of transacting necessary business, and in the organization of last year they asked to pay the expenses of that meeting which was being carried out in a more informal way than this year. Being in Chicago, the expenses were in the neighborhood of $2500.00. Those expenses were paid last year in toto by Surgery, Gynecology and Obstetrics, which means that they were paid by the men who are back of that publication. Then it was decided that we should have at this meeting a fee to cover the expenses of the meeting (it was said to be a nominal fee ), and we estimated that in all probability, basing the probable attendance on the registrations of last year, that it would require about a Five Dollar registration fee to cover the expenses. Now you can readily see that Surgery, Gynecology and Obstetrics is in no position, after they have spent $40,000 to $45,000 in launching the Journal and establishing it during the last six years, to pay the expenses of this Congress which as you see will be in the neighborhood of $6,000. In other words, every man who subscribes to Surgery, Gyne- cology and Obstetrics, we hope has subscribed with the idea that he will get Five Dollars worth of Journal without any side prize package Fellowship of Surgeons 467 of any kind. We also feel that every man coming here will be only too glad to not only pay the clerical hire and expense of this organization, but will be glad and anxious to pay for the money outlay of the physicians in the city in which the Congress is held. In other words, we are being entertained as we are not entertained in any other medical meeting because it is different from any other medical meeting. The hospitality of the city has been extended to us by the clinicians and they are doing the work, and we must insist (I do anyway) that they shall not be put to any financial outlay in entertaining us. At my last meeting with the Committee on Arrangements of Philadelphia, I begged of them, and they yielded reluctantly although not absolutely, to my request that we be allowed to pay for some of the entertainment—and those fees have been included (a very small part it is true) in the Treasurer's Report. Now what relation has the Journal to the Clinical Congress? Simply this: At the first meeting, Surgery, Gynecology and Obstetrics, since it had extended the first invitation, was made as a compliment to the Journal, the organ of the Clinical Congress. The men who were invited to attend this Congress, of course, included all those on the subscription list of Surgery, Gynecology and Obstetrics, ( 7,000 men) and in addition a selected list outside of that, up to the number of invitations issued, in the neighborhood of 12,000. Another thing: the Journal will publish the entire proceedings of the Congress, including reports of selected clinics, the transactions of the evening literary meetings, together with other information, in a bound volume which will be distributed to the members of the Con- gress. It would be impossible to secure that sort of a bound volume if it were not reprinted from the publication because the expense would be prohibitive—so that the Journal is back of the Congress to that extent. At some time it looks as though it would be necessary to limit the invitations to the Congress. If that time should come, it is natural to suppose that the invitations would go to those who have been the supporters of the Congress and the supporters of its official organ, but it will be some time before we are driven to any such extremity. The Five Dollar registration fee, was decided on, as I explained, because we hoped that the expenses would not exceed in the neighborhood of $6,000, and as our registration last year when we had no registration fee and what it was an informal affair in a way, reached 950, therefore, we were justified in expecting a 1,200 registration at this 468 Fellowship of Surgeons meeting. You see from the Treasurer's report that we shall fall below that. I shall be surprised if we reach 1,000 paid registrations. There is another thing that I wish to speak to you gentlemen about and that is to call your attention to the fact that there are a large number of floaters or deadheads attending clinics who have been attracted here by the invitation to this meeting. You have all seen them at all clinics. They are there early and they have no time to spend here because they are not expected here. They go to all the clinics, they get the front seats, and they increase in number as the clinic goes on. Now we have tried to overcome that by trying to impress upon the Committee on Arrangements in advance the necessity of keeping these men out. We begged to be allowed to pay for an orderly in each hospital so that we could control it to the extent that no man would be allowed to enter who was not vouched for either by a ticket or button or some other way. You know, you who have been attending the clinics, how little that rule was observed. I have been attending clinics and have been asked for my card once during the whole week. This allows anyone who comes to Philadelphia and who can in some way secure a program, to attend these clinics, and it is working to our disadvantage. We estimate that there are at least 300 men who have not registered, whose Five Dollars we ought to have and are entitled to, and if we did have the money, our expenses could be paid and not carried forward as last year by a private medical journal. I want to ask you in the next few days (although it is pretty late now) to quiz anyone you suspect of "float- ing"; ask him to show his card or button, and if he hasn't a button or ticket ask him why he is here; in other words make it just as uncomfortable as you can so that he will not care to come next year. And next year if we have a Congress, we shall have an orderly in every hospital, and if the hospital does not allow it, that hospital will come off the list, so that those who come here and pay the registration fee will have the best seats. I think that three or four men in registering here in the last week informed the registrar that they had been promised by some agent of ours, membership in this Congress, that his subscription to the Journal covered membership in the Congress and his registration fee at any meeting he might attend. If there are any here who took Surgery, Gynecology and Obstetrics with that idea in view, whether he understood aright or otherwise, I will be very much obliged indeed if he will come and allow us to return his money because no one has ever Fellowship of Surgeons 469 been authorized to make any such statement. A man who has subscribed to Surgery, Gynecology and Obstetrics is automatically a member of the Congress. That man does not have to pay for the expense of the meeting unless he actually attends it. If he does attend, next year, he is expected to help pay the expenses of that meeting. There is one thing I wish to bring up because it is apt to be brought up later. Why do we not allow the Journal and registration fee to be one? Because it is absolutely illegal. The delegates of the American Medical Association last year instructed the House to obey the law in that respect. The Mississippi Valley Medical Association which met last month separated the subscription price for their Journal from the registration fee because the United States Government will not allow them to accept a registration fee for a membership which will include a subscription. It is illegal and is absolutely impossible to any longer combine them. The American Medical Association is now working out a plan, as you know, that is to cover this point. So if we wanted to give the Journal, we could not do it. Thank you very much for your attention. 4. REPORT OF THE TREASURER FOR 1911 ( to 11/13/11) Receipts to 11/13/11 $4,230.00 Expenses Rent of halls $ 250.00 Reception expenses 400.00 Printing and mailing Invitations Printing $370.00 Addressing 25.00 Stamps 200.00 595.00 Letters 275.00 Postals 150.00 Headquarters expense: Clerks, assistants, daily programs, rooms, telephone service, rental of ballroom 1,000.00 Stenographic reports 105.00 Publication of transactions, including printing, binding, mailing (estimated) 1,000.00 Goldplated buttons 165.00 Stenographer's service for departments and places 960.00 Printing (miscellaneous) 225.00 470 Fellowship of Surgeons Office Expense: Manager's office and other expenses— trips to Philadelphia during year 385.00 Secretary's office and other expenses during year 300.00 $5,810.00 (For the expenses already met, Surgery, Gynecology and Obstet- rics has advanced the money.) In addition to the above there has been an expenditure of $1,350 for printing, publicity, etc., in Surgery, Gynecology and Obstetrics which has been borne by the journal. No salary has been paid to any officer. Respectfully submitted, (Signed) Allen B. Kanavel, Treasurer 5. SECRETARY'S REPORT, SECOND CLINICAL CONGRESS, PHILADELPHIA, NOVEMBER 11, 1911 The assured success of this Second Clinical Congress of Surgeons has confirmed what was demonstrated in the first meeting held in Chicago, namely: that a new want had developed among the men, great and small, who do surgery, which is adequately fulfilled in a series of operative clinics held in a place where the facilities are ample and where a coterie of the leading men in surgery can demonstrate each year to a large number of other surgeons not only the newest things but the highest example of routine work and methods of teaching—a great surgical clearing house with actual work instead of words as the medium of exchange. Fifteen hundred of us have traversed a continent to witness the surgeons of Philadelphia at work. We have gained two years in fa- miliarizing ourselves with the new things in surgery over those surgeons who remain at home and glean the new things from books. We not only learn new things but sharpen our wits by contact with each other and accumulate a store of enthusiasm besides having the satisfaction of knowing that we have imparted a lot of enthusiasm (and thus partially repaid our debt) to the strong band of Philadelphia clinicians who this year have furnished us our opportunity. Fifteen hundred surgeons who will travel thousands of miles and spend a fortnight of time in order to learn something and to store enthusiasm for their work must realize what a power for good the united efforts of such a band of men might exert if co - ordinated and divided aright. We have had an opportunity in these few days of witnessing the Fellowship of Surgeons 471 greatest teachers of surgery working in an environment of the greatest teaching institutions in our country. We must realize, however, that such an environment is none too good for any faculty of teaching surgeons, that the standard of requirements for the students in such institutions are none too high. We must realize, too, that many of the institutions that we know, and possibly some that we have been educated in or where we spent our years of teaching, are not up to the standard of these whose hospitality we have enjoyed and whose teachings we have admired. Can we go home to our own hospitals, to our own teaching institutions, and to our own classes, and be as well satisfied with them, if our hospitals are inadequate, our teaching institutions unequipped, and our students deficient in educational opportunities in comparison with those that we have admired here? We are about to choose our Congressional representatives. Our representative body consists of 1,100 members—corresponding to our United States Senators and members of the House of representatives; in other words, there are two representatives at large from each State in the Union, and one representative from each Congressional Dis- trict in each State; two representatives at large from each Province, and one from each constituency of Canada; two representatives at large from each Central American State and from each Colonial possession of the United States. One-half of these representatives are elected each year for a term of two years, and for each representative an alternate is appointed. As the members of the Congress from each State and Province meet today to elect their representatives, let me urge you to select those who stand for the highest ideals in surgery and are representative citizens of their respective constituencies. Our constitution prescribes no definite legislative duties for our representatives. Their positions are purely honorary and advisory in an organization whose object is purely scientific. While our organization is thus devoid of political significance, let the profession at large learn to look upon our representatives individually and collectively, as standing for the best movements in our great National, State and Provincial medical associations. The object of this meeting today is purely one of organization. Sometime, however, when we have emerged more fully from the experimental stage of our organization and have developed more fully the possibility of this clinical movement, some of which were pointed out by our President last evening, it is our hope that this representative body may have a definite work to do either independently or in co- 472 Fellowship of Surgeons operation with the great national medical associations of the United States and Canada along the lines of higher medical advancement. Now in regard to the appointment of representatives, appoint men who are actually doing work and who will be representative of the section from which they come; and who will be interested in this movement. Elect as far as possible representatives from among those who are in attendance as we want representatives who will actually attend the meetings of the Congress. If for any reason no members are present from any particular district, appoint men to fill the vacancies who will best represent that district 6. CONSTITUTION IV. The election of officers and the conduct of such other business as shall come before the Congress shall be under the direction of representatives. These representatives shall be known as Congressional and Senatorial Representatives, one Congressional Representative from each Congressional district of the United States and two Senatorial Representatives at large from each State; two Senatorial Representa- tives from each Province, and one Congressional Representative from each Parliamentary District of Canada; two Congressional Representa- tives from Mexico; two Congressional Representatives from each of the Central American Republics; two Congressional Representatives from each Colony of the United States; four Congressional Representa- tives from the United States Navy; four Congressional Representa- tives from the United States Army; and four Congressional Representa- tives from the Marine Hospital Service. The Surgeon-General of the Navy and the Surgeon-General of the Army and the Surgeon-General of the Marine Hospital Service, shall be Senatorial Representatives ex-officio. V. These Representatives shall be elected in the following manner: At each annual meeting of the Congress at an appointed hour, those in attendance from each State, each Province of Canada, the independent Republics of Central America, the United States Colonies, the United States Army, the United States Navy, and the Marine Hospital Service shall assemble and elect their representatives from among those present, for a term of two years. At the first meeting they shall elect the entire representation to be divided into two classes: one-half for one year and one-half for two years. After the first year, one-half of the representatives shall be elected for a term of two years. VI. If for any reason a division neglects to elect representatives, such representatives will be appointed by the executive committee. Fellowship of Surgeons 473 VII. The executive committee shall provide each year for a nominal registration fee to cover the expenses of administration. 7. FURTHER STATEMENT BY SECRETARY MARTIN, THIRD CLINICAL CONGRESS, NEW YORK CITY, NOVEMBER 15, 1912: I now wish to present a series of resolutions and I hesitate to do it, not because I do not consider it the thing to do, but because of the enormous amount of work that will be required to bring about results in what I expect to propose. I will read what I have to say in order that you may understand definitely what I mean:

PLANS FOR AN AMERICAN COLLEGE OF SURGEONS The spontaneous success of the Clinical Congress of Surgeons of North America, which in its third session has eventuated in an attendance of 2,600 surgeons, and which has on its list of members 9,000 names, demonstrates that something was needed in medical societies which this movement has supplied. Its unprecedented success places a great responsibility upon those who were instrumental in its conception. Personally, I feel that it presents great opportunities if the efforts of its organization are judiciously directed. It has solved in its three great meetings the primary object for which it was organized, viz.: the providing for its members the greatest of clinical opportunities. Through the editors of the surgical publication, by the invitation of which the first Clinical Congress was made possible, it has a plan (as was explained to you at the general meeting on Tuesday) by which a comprehensive journal of bibliography and abstract surgery will be established. At this time I wish to enlist the influence of this great organization of surgeons in a new effort, that will not only serve ourselves, but that will aid people who from tune to time look to us for surgical guidance. To be more definite, I believe that this largest organization of surgeons on the American Continent, the Clinical Congress of Sur- geons of North America, should assume the responsibility and the authority of standardizing surgery. This can begin at once by this body authorizing the appointment of a thoroughly representative committee, which committee shall have the power to act alone or in conjunction with other committees that this committee may invite to join them, along the following lines: First — It should formulate a minimum standard of requirements which should be possessed by any authorized graduate in medicine, 474 Fellowship of Surgeons who is allowed to perform independently surgical operations in general surgery, or any of its specialties. Second — It should consider the desirability of listing the names of those men who desire to practice surgery, and who come under the authorized requirements. Third — It should seek a means of legalizing under national, colonial, state or provincial laws, a distinct degree supplementing the medical degree, which shall be conferred upon physicians possessing the requirements recognized by this law as necessary to be possessed by operating surgeons. Fourth — It should seek co-operation with the medical schools of the continent which have the right to confer the degree of M.D., under the recognized standards, and authorize these colleges to confer the supplementary degree of Surgeons on each of its graduates as have, in addition to their medical course, fulfilled the necessary apprenticeship in surgical hospitals, operative laboratories and actual operative surgery. Fifth — It should authorize and popularize the use of this title by men upon whom it is conferred, and its use should especially be urged in all directories of physicians, in order that the laity as well as the medical man can distinguish between the men who have and the men who have not been authorized to practice surgery. In suggesting this innovation I appreciate the practical difficulties that will arise in carrying it to a successful execution. The difficulties can be surmounted, however, by a committee of this body backed by this organization, if the plan is worthwhile. I believe that the time is ripe for a concerted action on the part of the great body of thinking surgeons of this Continent, to insist that the surgeon of the future shall be not only throughly educated in the science of medicine, but that he shall have a thorough training in the technique of surgery under the direction of a practical surgeon before he is legally or morally allowed to operate upon the public. This is not, it seems to me, open to argument. This will protect unsuspecting patients who have no way of discriminating between trained surgeons and the tyro. It will protect the would-be surgeon against his own inexperience, and it will protect and put a premium where it belongs—on the conscientious trained surgeon. How shall we begin? We have in this body all the machinery and the talent that is necessary to make a successful campaign in establishing this reform. Remember, in every Congressional District in the United States, and in every parliamentary constituency of Canada, we have a representative surgeon in his community, who is a representative of this Congress. Besides, in each State of the United States, and Fellowship of Surgeons 475 each Province of Canada, we have two surgeons who have been chosen by their confreres as prominent in these large communities as representatives-at-large of this Congress. These men stand for real surgery, and each one will gladly co-operate with a committee from this Congress in making more valuable and honorable his position before his public and before his fellow-practitioners, by urging proper legislation through the co-operation of his neighbors. There is not a special surgical society in this country or Canada that will not welcome an opportunity to co-operate, through committee or individually, with a representative committee from this great continental organization of Surgeons. Believing this to be true, I move, Mr. President, that you be authorized to appoint a committee of nine members of this organization, of which the President and his immediate predecessor shall be two members, to consider the advisability of taking up this subject, and with power to act in any manner the committee may wish, and to report to this body at the next meeting of the Congress. DR. Join B. MURPHY: Mr. President, I rise to second that motion. There has not been presented to any surgical or medical organization that I have been connected with a resolution that is so comprehensive, so timely, so important, and so protective, for the surgeons and for the public as this resolution. I second it, Sir. There was presented a motion to the effect that the President be authorized to appoint a Committee of Nine of which the President and his immediate successor shall be ex-officio members, to consider the advisability of taking up this subject, and with power to act in any manner the Committee may wish, and to report to the Congress at the next meeting. Seconded and unanimously carried. The following Committee was appointed by President Edward Martin: W. W. Chipman, Montreal F. J. Cotton, Boston John M. T. Finney, Baltimore Franklin H. Martin, Chicago Rudolph Matas, New Orleans Charles H. Mayo, Rochester, Minn. John B. Murphy, Chicago Albert J. Ochsner, Chicago Emmett Rixford, San Francisco Edward Martin, Ex-officio, Philadelphia George Emerson Brewer, Ex-officio, New York City 8. BE rr RESOLVED by the Clinical Congress of Surgeons of North 476 Fellowship of Surgeons America here assembled, that some system of standardization of hospital equipment and hospital work should be developed, to the end that these institutions having the highest ideals may have proper recognition before the profession, and that those of inferior equipment and standards should be stimulated to raise the quality of their work. In this way patients will receive the best type of treatment, and the public will have some means of recognizing those institutions devoted to the highest ideals of medicine. The President of the Congress is hereby authorized to appoint a Committee from the profession, delegated to carry the spirit of this resolution into effect, and report at the Congress in 1913. A motion to the effect that the above resolution be adopted and a copy spread upon the minutes of the meeting was seconded by Dr. Frederic A. Besley, and the following committee was appointed by President Martin: Ernest A. Codman, Boston William j. Mayo, Rochester, Minn. Allen B. Kanavel, Chicago John G. Clark, Philadelphia W. W. Chipman, Montreal PRESIDENT MARTIN: It has been regularly moved and seconded that the committee having in view such standardization and supervision over hospitals, aiming to encourage those which are doing the best work and to stimulate those of inferior equipment and standard to do better, do consider and report upon the practicability of this work at the Congress in 1913. 9. BE rr RESOLVED that the time has arrived when if the surgeons of America are to do their duty to the citizens of this country that a campaign of publicity should be at once undertaken to bring to the attention of every woman in this country the early symptoms of cancer of the womb, and to point out that if the cancer be detected in its early stages that it can often be cured. BE rr FURTHER RESOLVED that this -Society at once appoint a committee of five to be named by the President to disseminate this information. AND FURTHER that this committee be instructed to write or have written articles to be published in the daily press, the weekly or monthly magazines, as may prove most expedient. AND FURTHER that they report their progress for the year to the next annual meeting of the Congress. Chapter 3 1. Incorporation STATE OF ILLINOIS Department of State Cornelius J. Doyle, Secretary of State To All to Whom These Presents Shall Come, Greeting: WHEREAS, a CERTIFICATE, duly signed and acknowledged has been filed in the Office of the Secretary of State, on the 25th day of November, A.D. 1912, for the organization of the AMERICAN COLLEGE OF SURGEONS under and in accordance with the provisions of "An Act Concern- ing Corporations" approved April 18, 1872, and in force July 1, 1872, and all acts amendatory thereof, a copy of which certificate is hereto attached; Now Therefore, I, Cornelius J. Doyle, Secretary of State, of the State of Illinois, by virtue of the powers and duties vested in me by law, do hereby certify that the said AMERICAN COLLEGE OF SURGEONS is a legally organized Corporation under the laws of this State. IN TESTIMONY WHEREOF, I hereto set my hand and cause to be affixed the great Seal of State. Done at the City of Springfield this 25th day of November, A.D. 1912, and of the Independence of the United States the one hundred and thirty-seventh. (SEAL) (Signed) C. J. Doyle, Secretary of State 2. These men were invited to attend the meeting of the Committee on Committees in Washington, May 5, 1913, at which the Organiza- tion Committee, increased from the original 11 by the addition of George W. Crile, presented plans for the formation of the College of Surgeons: Abbott, Amos W., Minneapolis Andrews, E. Wyllys, Chicago Baird, Alvin W., Portland Binnie, J. F., Kansas City Blanchard, R. J., Winnipeg Bloodgood, Joseph C., Baltimore I3ovee, J. Wesley, Washington Brinsmade, William B., Brooklyn 478 Fellowship of Surgeons Brown, John Young, St. Louis Bruce, Herbert A., Toronto Bunts, Frank E., Cleveland Byford, Henry T., Chicago Chown, H. H., Winnipeg Clark, John G., Philadelphia Coffey, Robert E., Portland Cullen, Thomas E., Baltimore Dickinson, Robert L., Brooklyn Eagleson, J. B., Seattle Ellis, H. Bert, Los Angeles Frick, W. J., Kansas City Gaub, Otto C., Pittsburgh Gellhorn, George, St. Louis Halpenny, Jasper, Winnipeg Halstead, Albert E., Chicago Hamann, C. A., Cleveland Huntington, Thomas W., San Francisco Hutchison, James A., Montreal Jackson, Jabez N., Kansas City LeConte, Robert G., Philadelphia MacKenzie, K. A. J., Portland MacLaren, Archibald, St. Paul Marlow, Frederick W., Toronto Matthews, James D., Detroit McKechnie, Robert E., Vancouver McMurtry, Lewis S., Louisville Moore, E. C., Los Angeles Moore, James E., Minneapolis Murphy, Fred T., St. Louis Painter, Charles F., Boston Peck, Charles H., New York Peterson, Reuben, Ann Arbor Pilcher, Paul M., Brooklyn Porter, Charles A., Boston Schenck, B. R., Detroit Sharples, C. W., Seattle Shepherd, F. J., Montreal Sherk, Henry H., Pasadena Sherman, Harry M., San Francisco Silverthom, G., Toronto Simpson, Frank F., Pittsburgh Smith, Richard R., Grand Rapids Stokes, Charles F., Washington Taylor, Howard C., New York Fellowship q Surgeons 479 Vaughan, George Tully, Washington Wathen, John R., Louisville Werder, X. 0., Pittsburgh Yocum, James R., Tacoma

3. The official call for the meeting of more than 300 surgeons at the New Willard Hotel, Washington, D. C., on May 5, 1913, follows: This meeting is called by a committee, authorized and appointed by the Clinical Congress of Surgeons of North America, which has for its object as stated in the language of the resolutions bringing it into existence, the following RESOLVED: That this largest organization of surgeons on the American Continent, the Clinical Congress of Surgeons of North America, shall assume the responsibility of standardizing surgery. This should be accomplished through a representative committee and along the following lines: First: It should formulate a minimum standard of requirements which should be possessed by an authorized graduate in medicine, who is allowed to perform independently surgical operations in general surgery or any of its specialities. Second: It should consider the desirability of listing the names of those men who desire to practice surgery and who come under the authorized requirements. Third: It should seek a means of legalizing under national, colonial, state or provincial laws, a distinct degree supplementing the medical degree, which shall be conferred upon physicians possessing the requirements recognized by this law as necessary to be possessed by operating surgeons. Fourth: It should seek co-operation with the medical schools of the continent which have the right to confer the degree of M.D. under the present recognized standards and urge these colleges to confer the supplementary degree of surgeon on each of its graduates who have, in addition to their medical course, fulfilled the necessary apprenticeship in surgical hospitals, operative laboratories, and actual operative surgery. Fifth: It should authorize and popularize the use of this title by men upon whom it is conferred and its use should especially be urged in all directories of physicians, in order that the laity as well as the medical man can distinguish between the men who have been authorized to practice surgery and those who have not. This committee "with power to act in any manner the committee may deem desirable" began its work by deciding to commit the final decision of the "desirability or the method of organization and the final accomplishment of an organization which would 480 Fellowship of Surgeons fulfill the spirit of instructions of the Congress authorizing the committee, to the strongest representation of surgeons that could be gotten together. The method pursued by the committee to accomplish what seemed at first a hopeless task is familiar to you all. The net result of the Committee's efforts is that five hundred surgeons of all specialities, representing every large center of population, every important university city with a teaching faculty of medicine, every special and general society representing a specialty of surgery, all the important surgical clinics and hospitals, besides many independent surgeons from all portions of the North American continent have consented to become founders of the organization under contemplation, and of this five hundred, fully four hundred are here at this hour to fulfill their obligation. As Secretary of this organization committee, I am authorized to call this meeting to order and ask you to elect a chairman to preside over your deliberation. 4. During the discussion on fee-splitting which took place at the first meeting of the Board of Regents in Minneapolis, June 17, 1913, Frank- lin Martin presented the following oath which was to be signed by each Fellow: THE OATH I pledge myself to live in accordance with the principles affirmed by the American College of Surgeons. I recognize that this association aims to exemplify the highest traditions and ideals of our most honorable calling; that it will seek the worthy; that it will establish and preserve enduring principles; that it will stimulate and fortify the character of its Fellows; and that it has for its supreme object the elevation of the standards of surgery. I pledge myself as a Fellow to pursue the practice of surgery with conservatism and to place the welfare of my patients above all else. I pledge myself to diligence in the pursuit of my calling; by study of its literature, by seeking the instruction of its eminent teachers, by interchange of opinions with associates and by attendance on important societies and clinics of the world. I pledge myself to conserve the interests of my professional brothers; to seek advice when in doubt of my own judgment; to willingly render any desired assistance to my colleagues and to freely give my services to the needy. I pledge myself to avoid, so far as the power within me lies, the sins of selfishness and to shun unwarranted publicity and dishonest money seeking. I recognize that ability and industry are the only means to real success and that unworthy commercialism is a menace to the honor Fellowship of Surgeons 481 and progress of our profession. I pledge myself not to stoop to secret money trades with consultants and practitioners in connection with fees received from patients entrusted to my care. On the contrary, I will endeavor to teach the patient his financial duty to his physician and urge the practitioner to obtain his reward openly from his patient. I will seek to make my fee commensurate with the services rendered and in accordance with the patient's rights and avoid casting discredit upon my associates by demanding unwarranted compensation. I recognize that the American College of Surgeons should be the repository of surgical progress and the clearing house of professional usages. I pledge myself to honor it; to follow its teachings; to fraternize with its Fellows; to propagate its principles and, as a member and a unit of this organization, I will conscientiously entrust its guidance to those most worthy among its Fellows to uphold its honor and to enhance its progress. 5. The following pledge was signed by each Fellow before his initiation at the first convocation. This, in fact, was the oath which Franklin Martin had proposed in Minneapolis to avoid having two declarations or pledges signed by the initiates. However, the declara- tive oath against fee-splitting specifically was signed by the first group of candidates. FELLOWSHIP PLEDGE Recognizing that the American College of Surgeons seeks to develop, exemplify and enforce the highest traditions of our calling, I hereby pledge myself, as a condition of fellowship in the College, to live in strict accordance with all its principles, declarations and regulations. In particular I pledge myself to pursue the practice of surgery with thorough self-restraint and to place the welfare of my patients above all else; to advance constantly in knowledge by the study of surgical literature, the instruction of eminent teachers, interchange of opinion among associates, and attendance on the important societies and clinics; to regard scrupu- lously the interests of my professional brothers and seek their counsel when in doubt of my own judgment; to render willing help to my colleagues and to give freely my services to the needy. Moreover, I pledge myself, so far as I am able, to avoid the sins of selfishness; to shun unwarranted publicity, dishonest money-seeking and commercialism as disgraceful to our profession; to refuse utterly all secret money trades with consultants and practitioners; to teach the patient his financial duty to the physician and to urge the practitioner to obtain his reward from the patient openly; to make my fees commensurate with the service rendered and with the patient's rights• and to avoid discrediting my associates by 482 Fellowship of Surgeons taking unwarranted compensation. Finally, I pledge myself to co- operate in advancing and extending, by every lawful means within my power, the influence of the American College of Surgeons. 6. The citation for Honorary Fellowships for Godlee, Keen and Hal- sted was patterned directly after university citations. Sir Rickman J. Codlee, student, versatile author, distinguished surgeon, worthy member of a family whose name is known and honored wherever antiseptic surgery is practiced, President of the Royal College of Surgeons of England, the highest honor within the gift of his professional associates at home. His presence here is a renewed evidence of the mutual high regard and esteem held for each other by the two great English-speaking nations. William Williams Keen, nestor of American surgery after a professional life covering fifty-two years. As a leader of the Jefferson School of Philadelphia, he links us with the great professional names of the nineteenth century. Army surgeon, teacher, operator, writer, publicist, traveler, patron of art, promotor of the best in higher education, public-spirited citizen, recipient of the greatest gifts in American medicine, Honorary Fellow of the Royal College of Surgeons of England and Edinburgh, he is honored throughout Europe. Wherever good surgery is regarded, there he is quoted. William Stewart Halsted, surgeon, teacher, investigator, honored at home and abroad; contributor to the progress of science. One of the four distinguished founders of the Johns Hopkins School of Medicine. His gifts to surgical technique, to numerous valuable operations now the standard, and to many great advances in surgical physiology and pathology, have brought to him international re- nown. Honorary Fellow of the Royal College of Surgeons of England and of Edinburgh, with undiminished vigor he still pursues his valuable career. 7. GREETING FROM THE ROYAL COLLEGE OF SUR- GEONS We, the Council of the Royal College of Surgeons of England, have heard with much interest of the approaching inauguration of the American College of Surgeons. We hereby convey to it our hearty good wishes, and express the hope that it may have a successful career and fill a position beneficial alike to the Profession and to the Community. We cannot forget the important advances in the Science and Art of Surgery achieved by many distinguished surgeons in the Continent of America during the past, and are proud to have enrolled upon our list of Honorary Fellows the names of some of the most active workers in these fields at the present day. Fellowship of Surgeons 483 In accepting the invitation for our President to take a part in the opening ceremony, we desire to show that we appreciate the intention of the American College to strengthen the bonds that already unite the Medical Profession amongst the English-speaking peoples. It is a sentiment which always meets with a cordial response in this country, and it is one which this College will endeavor to support by all the means in its power. In witness whereof we have caused the Common Seal of the Col- lege to be hereunto affixed this 9th day of October, 1913. President: RICKMAN J. GODLEE Vice-presidents: G. H. MAKINS ( SEAL) FREDERIC EVE Chapter 5 1. The recommendations of the Regents to the Fellows with an analysis of the problem of the location of the permanent home were: 1. As the College is recognized by intelligent folk as a guarantee of honesty and of competence in surgery, the work of the College exceeds in magnitude all previous conceptions of it. Few, even of the Fellows, realize the present headway of the College. The necessity of a great administrative building to serve as a central workshop is now beyond debate. If such a building is not provided for the College as a gift, it must be created by the College at its own cost in the near future. Need of an administrative building is imperative, for example, first, because of the task of hospital standardization undertaken by the College. This task is practically without end. It will require elaborate files and the keeping of much accurate data up to date. It will require a competent staff of workers in the field and offices from which will radiate the most progressive force toward the right training of physicians and surgeons and toward the proper care of sick people. A second need of an administrative building lies in the plan of admission to the College by examination. The responsibility of the College in this matter cannot be exaggerated. Not only must tons of papers submitted as evidence of fitness for Fellowship be gone over with exacting care, but also in the near future specific examinations will probably be required of the candidates personally at the executive headquarters of the College. Third, the management of adequate publicity as to the meaning of the College in our social fabric and of efforts toward better legislation among various states and provinces will require space not now available. And the increasing demands upon the general executive of tell, further, of the need of a real home for the College. Finally, a beautiful assembly hall for the Fellows in the proposed building is highly desirable. 2. As for the selection of Chicago as the home of the College, Chicago is within less than one hundred miles from the center of population of the United States and Canada. This fact is of para- Fellowship of Surgeons 485 mount importance. Further, Chicago is a metropolitan center easily accessible from all directions. 3. The value of a central location for the College is emphasized in the minds of the Regents by their hope, shared by many Fellows, that in the present generation there will be constructed on the one side of the administrative building a great medical museum with facilities for research, and, on the other, a great medical library. Such additions will undoubtedly come as gifts to the College if it reasonably fulfills the service to the public and to the profession to which it is now pledged. 4. Ultimately, as the proposed plans of the College unfold, the home of the College will become a real pantheon, wherein those who distinguish themselves for service in their profession shall receive a lasting recognition. The idea is that the College provide a systematic plan of recognizing distinguished merit among its Fellows by appropriate memorials in its home. 5. The custom among American and English colleges and universities to accept libraries, science buildings, chapels, etc., erected to the memory of men or women, who during their lives, were interested in the welfare of these institutions, is thoroughly established. The Hunterian Museum of the Royal College of Sur- geons, or the Harper Memorial Library of the University of Chicago, are familiar illustrations. There can be, therefore, no reasonable ground for objection to the acceptance of the proposed building as The John B. Murphy Memorial Hall of the American College of Surgeons. 2. The resolution formally authorizing the contract to be executed between the American College of Surgeons and the Murphy Memorial Association was presented by George E. Brewer of New York and seconded by Frederic J. Cotton of Boston:

RESOLVED, That the contract as submitted by The John B. Murphy Memorial Association be authorized, provided that a majority of the Fellows voting favor Chicago as the permanent home of the College, and provided that the Secretary of the College be empowered to agree to such minor changes in the contract as he may deem wise for the best interests of the College; and BE rr Fuwrnna RESOLVED, That the Regents authorize said contract as stated with sincere gratitude and appreciation to The John B. Murphy Memorial Association, believing that the proposed memorial will serve as a lasting and as the most appropriate monument to the late Dr. Murphy who gave to the College his high creative inspiration and his invaluable energy without reserve. 486 Fellowship of Surgeons 3. The contract which was approved provided that the Murphy Memorial Hall of the American College of Surgeons should be known for all time by that name: It is agreed by and between THE JOHN B. MURPHY MEMO- RIAL ASSOCIATION, a corporation not for pecuniary profit, organized under the laws of the State of Illinois, hereinafter referred to as the ASSOCIATION, and the AMERICAN COLLEGE OF SURGEONS, a corporation not for pecuniary profit, organized under the laws of the State of Illinois, hereinafter referred to as the COLLEGE, as follows: (1) The parties hereto agree to co-operate in securing a fund of at least $500,000. (2) Such fund shall be deposited, as received, with as Trustee, to be expended in the manner hereinafter provided and in no other manner. (3) Such fund shall be used only for the erection of a building as a memorial to JOHN B. MURPHY, for the purchase of a suitable site and for the payment of incidental expenses. (4) Such building shall be erected in the city of Chicago on a site selected by the Association, title to which shall be vested in the College except that in case a site acceptable to the Association in some public ground, or the use thereof, be donated, the matter of title shall be arranged between the donor and the Association. (5) Such building shall be known for all time as "THE JOHN B. MURPHY MEMORIAL HALL OF THE AMERICAN COL- LEGE OF SURGEONS" and shall be permanently so designated by a tablet to be built permanently into the building. (6) When the full $500,000 shall have been procured, or sooner if it is deemed advisable to do so, the Association will employ one or more architects to prepare plans and specifications and to supervise the erection of such building. Such plans and specifications shall be subject to the approval of a Building Committee of four members, two to be named by each party hereto. The Association will enter into all building contracts necessary to the completion of such building according to such plans and specifications. When the building shall have been completed it shall be conveyed by the Association to the College, together with title to the site on which it is located — except that in case the building be erected on public grounds, then the matter of title shall be arranged as provided in paragraph numbered 4 hereof. The College will provide all the furnishings - not fixtures - for the building at its own sole cost and expense. (7) Provision, suitable in the opinion of the Building Committee Fellowship of Surgeons 487 shall be made in the plans for a pantheon of American medicine and surgery, in which shall be received according to rules of the College tablets, statues, medallions, etc., to commemorate persons who have made notable contribution to the advancement of medicine or of surgery on the American continent. (8) The fund aforesaid shall be paid out by the Treasurer of the Association on vouchers of the Association countersigned by the Secretary of the College. (9 ) Such building shall be perpetually and solely occupied by the College, which shall maintain the same perpetually at its own sole cost and expense, pay all taxes, special assessments, and all other charges of every character, and keep the building insured against destruction or loss by fire, cyclone or earthquake. And all moneys received on any insurance policy shall be used exclusively to repair or restore such building. 4. The following assignment from Edward C. Kendall to the Amer- ican College of Surgeons was made on January 6, 1917. Because of the lack of a quorum at the January meeting, it was accepted by the Regents on February 3, 1917.

KNOW ALL MEN BY THESE PRESENTS, that whereas I, Edward C. Kendall, of the Mayo Clinic of Rochester, Minnesota, have discovered a process for the isolation of the active constituent of thyroid, which I desire to protect from exploitation by private manufacturers and dealers, and WHEREAS, I have applied for letters patent thereon, Now, THEREFORE, to prevent the exploitation of said discovery, and in order that it may be kept for the benefit of the profession and the public, I hereby assign all right, privilege and patent, if issued, to the American College of Surgeons, as Trustee, to do with as it sees fit for the benefit of the profession and the public upon condition that said American College of Surgeons agrees to control the production and the purity of the substance. It is further stipulated that should any profit be derived to the American Col- lege of Surgeons from its sale and distribution, such money shall be used for medical research. In Testimony Whereof, I have hereunto set my hand and seal this 22nd day of November, A.D. 1916. (Signed) EDWARD C. KENDALL, Seal (Signed) EDWARD C. ROSENOW Witnesses: H. S. PLUMMER 5. The first plan of affiliation submitted by the committee appointed 488 Fellowship of Surgeons to merge the Clinical Congress of Surgeons of North America and the American College of Surgeons was: We, the members of a joint commission appointed to propose a basis of affiliation between the Clinical Congress of Surgeons of North America and the American College of Surgeons, said committee consisting of the Ex-Presidents of the Clinical Congress of Surgeons of North America and a committee appointed by the Regents of the American College of Surgeons, authorized by resolutions with power to act, make the following recommendations: 1. That the annual meeting of the Clinical Congress of Surgeons of North American and the Convocation of the American College of Surgeons be held each year during the same period and in the same city. 2. That the name of the Clinical Congress be hereafter the Clin- ical Congress of the American College of Surgeons. 3. That membership of the Congress shall consist of those who make advance registration each year to the limit of attendance agreed upon between the Executive Committee of the Congress and the Committee of Arrangements representing the city of meeting, from an invitation list hereinafter provided. 4. That the invitation list of the Clinical Congress of Surgeons shall consist of the Fellows of the American College of Surgeons and all members of the Congress as fixed by the present by-laws, who will sign the following declaration adopted by the Congress in October, 1916. I hereby declare that I do not and that I will not engage in the practice of the division of fees under any guise whatever; that I neither collect fees for others referring patients to me; nor permit others to collect fees for me, nor make joint fees with physicians or surgeons referring patients to me for operation or consultation, nor will I knowingly permit any agent or associate of mine to do so. 5. That there shall be no annual dues for members of the Con- gress, but that a registration fee to cover the usual expenses incurred by each meeting shall be required of members at the time of registration. 6. That the officers and Executive Committee of the Congress remain as fixed by the present by-laws of the Congress, and be chosen by nomination made by the joint action of the Executive Committee of the Congress and of the American College of Sur- geons. 7. That the by-laws of the Congress shall be changed to conform to these recommendations. Chapter 6 1. The minimum standard for hospitals outlined by Director John Bowman and adopted by the Regents on December 20, 1919, was: 1. That physicians and surgeons privileged to practice in the hospital be organized as a definite group or staff. Such organization has nothing to do with the question as to whether the hospital is "open" or "closed," nor need it affect the various existing types of staff organization. The word staff is here defined as the group of doctors who practice in the hospital inclusive of all groups such as the "regular staff," the "visiting staff," and the "associate staff." 2. That membership upon the staff be restricted to physicians and surgeons who are (a) competent in their respective fields and (b) worthy in character and in matters of professional ethics; that in this latter connection the practice of the division of fees, under any guise whatever, be prohibited. 3. That the staff initiate and, with the approval of the governing board of the hospital, adopt rules, regulations, and policies governing the professional work of the hospital; that these rules, regulations, and policies specifically provide: (a) That staff meetings be held at least once each month. (In large hospitals the departments may choose to meet separately.) (b) That the staff review and analyze at regular intervals the clinical experience of the staff in the various departments of the hospital, such as medicine, surgery, and obstetrics; the clinical records of patients, free and pay, to be the basis for such review and analyses. 4. That accurate and complete case records be written for all patients and filed in an accessible manner in the hospital, a complete case record being one, except in an emergency, which includes the personal history; the physical examination, with clinical, pathological, and x-ray findings when indicated; the working diagnosis; the treatment, medical and surgical; the medical progress; the condition on discharge with final diagnosis; and, in case of death, the autopsy findings when available. 5. That clinical laboratory facilities be available for study, diagnoses, and treatment of patients, these facilities to include at least 490 Fellowship of Surgeons chemical, bacteriological, serological, histological, radiographic and fluoroscopic service in charge of trained technicians. 2. Samuel Nickerson was born in Massachusetts. After serving an apprenticeship in his brothers' mercantile store in Florida, he started his own business. He was burned out and in 1858 moved to Chicago at the age of 28 where he became a distiller of alcohol and high wines. In eight years he retired from his business and became the president of the Chicago City Horse Railway. He assisted in organizing the First National Bank and became its second president in 1867. The Nickersons accumulated a large collection of Japanese, Chinese and East Indian objects of art during their years of travel. They presented these, a collection of modern paintings and one of the finest collections of jades, agates and crystals in the United States to the Art Institute of Chicago. The three-story house was designed by Edward Burling, a Chicago architect, and the interior finish was done by A. Fiedler, for years a designer for one of the leading decorative and art furniture manufacturers of New York. The onyx pillars, alabaster banisters, tiled fire- places, parquet floors, mantels of rare inlaid woods, beamed ceilings, brass, copper and glass chandeliers, leather-paneled walls, richly carved oak, walnut and red, bleached and ebony finish mahogany woodwork resulted in a palace-like dwelling. In 1900, the Nickersons sold their home to Lucius Fisher, who was born in Beloit, Wisconsin, and came to Chicago in 1865. Rapidly, Fisher advanced from a porter for the Rock River Paper Company to the presidency of the Union Bag and Paper Company. He acquired large real estate holdings in Chicago and in the West, including mines and irrigation projects. Fisher died in 1916 and his estate was being settled when the American College of Surgeons acquired the property. Chapter 7

1. The gavel presented by Sir Rickman Godlee, Lord Lister's nephew, was a mallet which Lister had used in his surgical operations. The following description of the mace is taken from Franklin Martin's The Joy of Living: The Great Mace retains the traditional shape and proportions of the civic mace of the Seventeenth Century, and is of hand- wrought, chiseled and repousse silver gilt. It was made by Omar Ramsden. The crown-shaped finial is formed of six rich scroll buttresses which uphold the "Sacred Flame of Science." These buttresses spring from a cresting composed of alternating maple leaves and American eagles, intertwined with the serpents of Aesculapius. On the band below appear the words "The American College of Surgeons." The body or head is divided into six panels by the winged Caduceus, insignia of the U. S. Army medical corps. The panels set forth the full blazon of the United States, the Dominion of Canada, the Royal College of Surgeons of England, the badge of the Royal Army Medical Corps, the shields of arms of John Hunter and Lord Lister, and a cartouche bearing the words "Philip Syng Physick 1768-1837, Father of American Surgery." The lower portion of the head is decorated with a symbolic band of water, indicating the ocean which both unites and separates America and the Mother Country. British lion brackets support the head, and terminate the upper part of the staff. The staff is decorated with a free design of the national floral emblems of the United Kingdom—the rose, the thistle, the sham- rock, and the leek. Intertwined are a number of ribbon scrolls, each one of which bears the name of a donor. The various parts are held together, in the traditional manner, by a rod of British oak, cut from a tree grown at Wytham, Berks. The extreme length is three feet, eleven and one-fourth inches and the weight of silver is 140 ounces troy. The mace was presented to the College at the Montreal meeting in October 1920. 492 Fellowship of Surgeons 2. The petition presented by Dean D. Lewis for the Society of Clinical Surgery on June 12, 1924, read: At a meeting of the Society of Clinical Surgery, held in Roches- ter, Minnesota, June 6, 1924, a resolution was passed endorsing the aims and objects of the American College of Surgeons, and a Committee appointed to convey to the Board of Regents the following suggestions: 1. That the number of Fellows admitted to the College each year be immediately reduced, and that those admitted be distributed as needed in the country providing that they meet the requirements. 2. That a change be made in the methods of examining candidates so that more rigid tests could be made as to the character, training and intelligence. 3. That the candidates rejected because of defects in or lack of character be not considered again for at least three, and preferably, five years, and that the State Committees be instructed that the terms "Rejected" and "Not Recommended" are not synonymous. 4. That proselyting of members be stopped, membership of those applying for admission being more valuable than that of those who are invited. Members: Dr. Dean Lewis, Chairman Dr. G. J. Heuer Dr. J. L. Yates Dr. E. Starr Judd Dr. E. Wyllys Andrews 3. The following petition was presented by the Eclat Society on June 12, 1924: We are in hearty accord with the conception of the American College of Surgeons as expressed in the year book of 1915. "It is a society, or a College in the original sense, whose reason for existence lies in its disinterested and unselfish efforts to raise the standards of the profession, moral as well as intellectual, to foster research, and to educate the public up to the idea that there is a difference between the honest, conscientious, well-trained surgeon and the purely commercial operator. It aims to include within its fellowship only those surgeons who are competent in the science and technique of surgery and who have in them the moral timber which characterizes a fine conception of public service." With the objects so clearly stated there was a keen enthusiasm Fellowship of Surgeons 493 for the organization during its early period, but later there developed a lack of interest and a disappointment, and then a dis- satisfaction which in certain quarters seems to threaten more or less open antagonism. There is a widespread impression that the present membership includes men that have not the highest ideals, who are either fee-splitters or are generally reputed to be paying commissions under one guise or another. There has been no evident effort to clean house; indeed, it has been repeatedly stated that men have been admitted who have been unfavorably reported by their State Committee on Credentials. There is a conviction that many of the men admitted do not measure up to the original standard and that many are immature. This makes it seem advisable to hold an annual Congress of Sur- gery to give instruction to these men. Reports from these meetings raise a reasonable doubt as to the benefits derived in an educational way. The meetings are a great burden to the city that undertakes them and are not sought. It is intimated that in one instance, the Congress was held despite the opposition of a great number of the surgeons in that community. There is a question of the taste used in dealing with the publicity at these meetings, and we suggest that the laity be advised of the advances in medicine and surgery without the use, or at least without stress on the author's name. Displeasure has been expressed at the seemingly arbitrary way the affairs of the College have been managed. Much of the responsibility has fallen on the Director, and he has appeared to assume that he can dictate what shall be done rather than following the advice of the Regents in developing and maturing their plans. There has also been a frequent questioning of the financial affairs of the College, inasmuch as there has never been issued a satisfactory financial statement. We believe that the College can take a long step to reinstate itself in the confidence of its original members by getting rid of dishonest members who are recognized as fee-splitters, or those who pay commissions, and by announcing to the profession that these men have been dropped. We believe that in the future fewer candidates should be admitted, and suggest that candidates that have been twice rejected by the State Committee on Credentials should not be brought up for consideration except by special vote of the Regents. We believe that more effort should be made to encourage research and less emphasis placed on the annual Congress and regional clinical meetings. 494 Fellowship of Surgeons We believe that the Regents should assume much of the responsibility now undertaken by the Director. We strongly urge that a comprehensive itemized financial statement be published yearly. The standardization of hospitals by the College has accomplished much good. If it is to be continued, its purpose should be to stimulate the better hospitals to more effective service and to higher types of investigation by raising the qualifications for recognition. The maintenance of low standards, though many institutions may be recognized, defeats the purpose of this movement. We believe that higher standards should be used, and that only those qualified to judge the values of hospital service be employed in making the investigation, and that more attention be paid to the quality and that less be paid to the quantity of work done in and by hospitals. No hospital admitting patients of fee-splitters should be recognized. We believe that the plan to organize a Junior Candidate Group will not tend to elevate the younger men as much as it will give them an opportunity to advertise the fact that they are in the College, and the public will not differentiate between a junior and a senior member. By adding the junior group we only increase the membership without raising the standards. If the standards of the College are made high enough, there will be sufficient attraction to enlist all the best men. We believe that the American College has achieved so high a place in the profession of America that too much effort should not be given to the development of the numerical and financial strength at the expense of dignity, sound selection of members and a genuine idealism in professional standards. Chapter 9 1. Resolutions adopted by the House of Delegates at the Cleveland Session of the American Medical Association, June 12, 1934.

WHEREAS, The American Medical Association, including 100,000 physicians, is the only democratic body representing the organized profession of this country through delegates regularly elected through county and state medical societies; and WHEREAS, Other medical organizations and groups, representing selected groups of specialists, have from time to time issued pro- nouncements of policies in the field of medical economics and medical practice, which do not represent the views of organized medicine and which purport to guide the medical profession and the public in the administration of medical affairs; and WHEREAS, The House of Delegates of the American Medical As- sociation has repeatedly condemned the issuing of such announcements and policies, which seriously embarrass the attempts of this organization to secure adequate care for the health of the American people and to protect the ideals of the medical profession; and WHEREAS, The Board of Regents of the American College of Surgeons, assembled in Chicago on Sunday, June 10, promulgated a policy including a prepayment plan for medical care, restricted to so-called "approved hospitals" to members of the staffs of such hospitals, and to physicians acceptable to such staffs; and WHEREAS, This action of the Board of Regents of the American College of Surgeons has been spread to the people of the United States through the public press on the opening day of the annual session of this House of Delegates; therefore, be it RESOLVED, That the House of Delegates of the American Medical Association express its condemnation of such tactics and of this apparent attempt of the Board of Regents of the American College of Surgeons to dominate and control the nature of medical practice, and be it further RESOLVED, That the House of Delegates request the Board of Trustees of the American Medical Association and the Judicial Council to ask the Board of Regents of the American College of Surgeons, who are themselves members of the American Medical Association, to explain the reasons for their action and to justify 496 Fellowship of Surgeons the attempt by this small group with a specialistic organization to legislate for all the medical profession of this country, truly represented only by the American Medical Association. 2. The following material from the Journal of the Indiana Medical Association, 27: 305, 309, 345, 1934, was expressive of the views and arguments advanced by the hard core of opposition to the College which still existed among general practitioners in the medical profession: EDITORIAL NOTES A recent pronouncement of the Board of Regents of the Amer- ican College of Surgeons seems likely to have gotten that group into a bit of hot water. The American Medical Association House of Delegates adopted resolutions on the matter in no uncertain terms and have demanded some action on the part of the board or the college. Just why a little coterie of men should take it upon themselves to pass upon such an important question as health insurance is beyond us; certainly it is a matter that concerns all practitioners of medicine, and they should have some voice in such an important matter.

PROCEEDINGS OF THE CLEVELAND SESSION OF THE A.M.A. June 11-16, 1934 Criticism of the Board of Regents of the College of Surgeons was voiced in a resolution introduced by Dr. Charles J. Whalen of Chicago, for recommendation of a "prepayment plan" (contract health insurance) of payment for services in approved hospitals. The action was referred to as an apparent attempt of a small group of specialists to dominate and legislate for the entire profession. MEN IN WHITE (Editorial) Keen-visioned, decisive, perspicacious, masters of life and death are these men in white, these physicians who as members of the American College of Surgeons are among the select of their profession when they work under the intense brilliance of the flood- lighted surgery. Blundering, arrogant, visionary and publicity hunting opportunists are these self-same men in white when they set themselves up under the dazzling light of the public gaze to speak for the rank and file of the medical profession in the matter of medical economics. This is the general appraisal of the rank and file member of the Indiana medical profession when he has recovered sufficiently from his surprise to comment upon the now notorious resolution presented by the Medical Service Board and adopted by the Board of Re- gents of the American College of Surgeons, and given wide publicity. Fellowship of Surgeons 497 This resolution which caused the repercussion of criticism against the college at the recent American Medical Association meeting in Cleveland states that "The periodic prepayment plan providing for the costs of medical care of illness and injury of individuals and families of moderate means offers a reasonable expectation of providing them with more effective methods of securing adequate medical service." All of which to John Average Doctor, M.D., means nothing more nor less than that the college has "come out" for group hospital and medical insurance and consequently socialized medicine. The resolution apparently was the last straw and many comments concerning the failure of the American College of Surgeons to live up to the highest traditions and ideals of the medical profession which heretofore have been whispered in low tones now are being broadcast on broad wave lengths both by men who are members of the college and by those who are not. Outstanding among these open criticisms of the college and its leaders, picked up from conversations wherever physicians may gather, are the following: "The College of Surgeons has overstepped its bounds in attempting to force the profession into some form of socialized medicine." "The American Medical Association and not the College of Sur- geons is the true mouthpiece of the profession on matters of economic and social importance." "The American College of Surgeons should confine its interests and activities as an organization to purely scientific matters." "Some certain physicians with nation-wide reputations have used the College of Surgeons and other special organizations as a sounding board to promote their own personal publicity." "Sure, the A.M.A. was asleep, but what right has the College of Surgeons to standardize hospitals and set up rules and regulations for these institutions? That should be the work of the A.M.A. Council on Hospitals." "The College of Surgeons apparently has a code for the big shots and another very strict code for the little fellows." "What about the report that an officer representing the College of Surgeons has made a trip to Washington and has attempted to sell the President upon some form of health insurance under the guise that the College of Surgeons, containing the elite of the profession, is the proper spokesman for the profession in such matters?" Others of much more personal tone and specific accusation have been expressed against leaders in the college—men of prominence and high standing in the profession. From the above bits of conversation it is plain that the College 498 Fellowship of Surgeons of Surgeons has lost much of the confidence of the profession in general and gives some of the reasons why many of these lesser "men in white" who do not desire the dazzling light of publicity and who make up the large mass of the college are this minute pondering as to whether it is better to resort to radical surgery or resign from the case and let the patient pass on to an agonizing but natural death. 3. Although no formal action had been taken in October 1934 by the Board of Regents to implement a meeting between them and the Board of Trustees of the American Medical Association, such a meeting was arranged informally. Robert B. Greenough, Charles Dukes of Oakland, California, Frederic Besley of Waukegan, Illinois, and Marion T. Farrow and Eleanor K. Grimm of the administrative staff, represented the College. Walter Bierring of Des Moines, Iowa, and E. J. Cary of Dallas, Texas, represented the American Medical Associ- ation. This meeting was held on Sunday, February 17, 1935, in the Palmer House, Chicago. Doctors Bierring and Carey pleaded strongly for a joint statement to come from the American Medical Association and the American College of Surgeons expressing approval of a resolution passed the day before in a special session of the House of Delegates. Bierring said that he had been assured that a telegram from President Roosevelt would be sent for him to read before the assembled delegates, but none had been received. His disappointment was only increased by a telegram from Dr. Ross McIntire, the President's physician, saying that he could not get in touch with the President. Bierring urged action by the Board of Regents because of the influence which the College had in Washington, in an effort to forestall the presentation of a program for health insurance which the President was to present to Congress on March 1. The American Medical Association House of Delegates had been assembled in a special session a few days previously and had reversed the position taken the previous June. In fact, the delegates had recommended that the Bureau of Economics be instructed to draw up plans for health insurance to be submitted to the House of Delegates at their meeting the following June. Bierring and Carey suggested that the Regents be polled by post- card for their vote in order to support a joint action between the two organizations. Later that day the College representatives at the luncheon met with Fellowship of Surgeons 499 Bowman C. Crowell, Associate Director of the College, in the absence of Franklin Martin, and recounted the luncheon discussion, Greenough, Dukes and Besley were enthusiastic about the opportunity of co- operating with the Trustees of the American Medical Association. Crowell put a damper on their enthusiasm by recounting the past history of relations with the Association and saying that now their representatives were asking the College to strengthen their hand in Washington and their influence on members of both organizations. Crowell was successful in influencing the three Regents to advise Franklin Martin that no action should be taken until the matter could be presented to the entire Board of Regents. The result was that on April 6, 1935, the Regents formally agreed to accept a future invitation to meet with the Trustees of the American Medical Association. Chapter 12 1. At the various conferences held to discuss co-operation in a hospital standardization program, the four organizations interested were represented by the following individuals: American College of Surgeons Arthur W. Allen, M.D. Warren H. Cole, M.D. Eleanor K. Grimm Evarts A. Graham, M.D. Paul R. Hawley, M.D. Alton Ochsner, M.D. Malcolm T. MacEachern, M.D. Fred W. Rankin, M.D. American College of Physicians Alex M. Burgess, M.D. Reginald Fitz, M.D. George H. Lathrop, M.D. William S. Middleton, M.D. George M. Piersol, M.D. Maurice C. Pincoffs, M.D. LeRoy H. Sloan, M.D. Wallace M. Yater, M.D. American Medical Association Donald G. Anderson, M.D. Gunnar Gundersen, M.D. Elmer L. Henderson, M.D. Edward H. Leveroos, M.D. George F. Lull, M.D. Edward J. McCormick, M.D. Edwin Hamilton, M.D. American Hospital Association Arthur S. Bachmeyer, M.D. George Bugbee Frank R. Bradley, M.D. Msgr. John J. Healy John H. Hatfield Maurice J. Norby Fellowship of Surgeons 501 Anthony J. J. Rourke, M.D. Charles F. Wilinsky, M.D. 2. A resolution was adopted on April 3, 1948, by a subcommittee consisting of Frederick A. Coller, Dallas B. Phemister, Malcolm T. MacEachern and George H. Miller from the American College of Surgeons, Harvey B. Stone, Donald G. Anderson and Edward H. Leveroos from the Council on Medical Education and Hospitals of the American Medical Association and Guy A. Caldwell and Warfield M. Firor representing the specialty boards. It was rewritten as follows for transmission to the Board. of Regents of the American College of Surgeons and the Board of Trustees of the American Medi- cal Association on July 9, 1949:

RESOLVED, That mutually acceptable standards for residency training in surgery and the surgical specialties be drafted by a committee appointed by the Chairman of the Subcommittee on Hospital Problems and representing the Council on Medical Edu- cation and Hospitals and the American College of Surgeons; the standards so formulated to be referred to the appropriate bodies of the parent organizations for ratification. BE IT FURTHER RESOLVED, That a single uniform list of institutions approved for residency or graduate training in surgery and the surgical specialties be published by the Council on Medical Edu- cation and Hospitals and the American College of Surgeons. The committee authorized in the previous resolution is also charged with formulating recommendations as to the specific procedures to be followed in preparing and publishing such a list. BE rr FURTHER RESOLVED, That the Chairman of the Subcom- mittee on Hospital Problems be authorized to appoint a committee to study ways and means of effecting a single survey service and that this committee report back to the Subcommittee on Hospital Problems at the earliest possible date. Chapter 13 1. The following resolution protesting the creation of the Interna- tional Board of Surgery by the International College of Surgeons was adopted by the Board of Regents of the American College of Surgeons at its meeting in Hot Springs, Virginia, on December 3, 1951:

WHEREAS there are existing American Boards for certification in general surgery and each of the surgical specialties; and WHEREAS these American Boards, in their standards and in the application of such standards, have significantly contributed and continue to contribute to the elevation of the quality of care and treatment of the surgical patient to the highest level yet obtainable in American surgery; and WHEREAS there can be no logical justification for the establishment of other certifying boards in the same professional fields; and WHEREAS the International College of Surgeons has established certifying boards in general surgery and the surgical specialties; and WHEREAS, in the opinion of the Board of Regents of the American College of Surgeons, the application of standards fixed by the boards of the International College of Surgeons is not in accordance with the generally accepted principles of education and training upon which competence in surgery is evaluated; and WHEREAS most patients, in their selection of surgeons, are unable to distinguish between two standards for certification; THEREFORE BE rr RESOLVED that the American College of Sur- geons deplores the establishment of certifying Boards other than those approved by the Advisory Board for Medical Specialties, and regards such actions as constituting a menace to present standards in the practice of surgery and to their further elevation; and BE rr FURTHER RESOLVED that it is the sense of the Board of Regents of the American College of Surgeons that no Fellow of the American College of Surgeons should support, in any manner whatsoever, the establishment and perpetuation of certifying boards other than those approved by the Advisory Board for Medical Fellowship of Surgeons 503 Specialties, or support any organization which sponsors such other certifying boards; and BE IT FURTHER RESOLVED that a copy of this resolution be sent to each Fellow of the American College of Surgeons and to each established American Board for certification in surgery and the surgical specialties. 2. The first report on unethical practices was made by the Pro- fessional Relations Committee of the Board of Regents of the Ameri- can College of Surgeons on April 13, 1951: Fee-splitting is condemned by the American College of Surgeons because that practice is not in the best interest of the patient. DEFINITION OF FEE-SPLITTING Fee-splitting is defined as a practice in which part of the professional fee, paid to a physician or surgeon, is given (by subterfuge or otherwise) to a third party, usually the referring physician. PRACTICES CONDEMNED AS NOT BEING IN THE BEST INTEREST OF THE PATIENT 1. Practices which are classified as fee-splitting: a. The surgeon charges a fee and remits part of it to the referring physician. b. The surgeon operates on the patient, and is paid for his services by the referring physician. On many such occasions the role of the surgeon is unknown to the patient, or to the responsible party, thus giving rise to the term "ghost surgery." c. The referring physician acts as an assistant at the operation, giving the anesthetic, or performs a function in the postoperative care, and receives payment for these services from the surgeon. If a qualified surgical resident is available as an operative assistant, and/or a qualified anesthetist is available for giving the anesthetic, the referring physician should not act in either capacity. Such subterfuge is not necessary to justify adequate remuneration of the referring physician for his medical responsibility to the patient. 2. Practices which are classified as being unethical: The practice of accepting a rebate or commission from the charge made by a company for material ordered from them for a patient is considered unethical. MEANS OF COMBATING FEE-SPLITTING 1. On many occasions the general practitioner or referring physician is not getting enough money for his time spent in taking care of the patient initially, and making the diagnosis. The American College of Surgeons strongly urges that the surgeon emphasize to the patient the great value of initial care (including making the 504 Fellowship of Surgeons diagnosis), and likewise that he be paid adequately for his services. 2. The American College of Surgeons condemns overcharging of the patient by the surgeon, on the basis that this practice is (a) unjust, and (b) encourages fee-splitting because the patient's financial reserves are so depleted that the referring physician cannot be paid adequately for his medical services. 3. The public should be educated to the value of the referring physicians' services. 4. Faculties of Medical Schools should emphasize more strongly than previously the evils of fee-splitting to young physicians and surgeons in training, and insist that they avoid this practice at all costs. 5. The elected candidates of the American College of Surgeons should sign a notarized pledge so worded that they might be guilty of perjury if they practice fee-splitting. 6. The fellowship of a few Fellows known to be fee-splitters, should be cancelled and others, guilty of the evil without positive proof, should be removed from important positions or offices in the American College of Surgeons. 7. There should be encouragement of the policy, recently adopted, to have panel discussions on fee-splitting in our College Sectional Meetings. 8. The formation of Grievance Committees by County and State Societies should be encouraged by offering public support to the efforts of these groups. 9. The surgeons should be educated to the fact that the surgeon's fee should be limited by the patient's ability to pay, and the amount determined, in part, by other medical expenses. 10. The surgeon should consult more freely with referring physicians with regard to the patient's ability to pay. 11. The College should notify the Department of Internal Rev- enue that the American College of Surgeons disapproves of fee- splitting. 3. The second and final report on unethical practices was made by the Professional Relations Committee of the Board of Regents of the American College of Surgeons on November 9, 1951:

Fee -splitting is condemned by the American College of Surgeons because that practice is morally wrong, and is not in the best interest of the patient, the public and the medical profession. DEFINITION OF FEE-SPLITTING Fee-splitting is defined as a practice in which part of the professional fee, paid to a physician or surgeon, is given (by subterfuge or otherwise) to a third party, usually the referring physician. Fellowship of Surgeons 505

PRACTICES CONDEMNED AS NOT BEING IN THE BEST INTEREST OF THE PATIENT Practices which are classified as fee-splitting: a. The surgeon charges a fee and remits part of it to the ferring physician. b. The surgeon operates on the patient, and is paid for his rvices by the referring physician. On many such occasions the le of the surgeon is unknown to the patient or to the re- )onsible party, thus giving rise to the term "ghost surgery." c. The referring physician acts as an assistant at the operation, yes the anesthetic, or performs a function in the postoperative ire, and receives payment for these services from the surgeon. If a qualified surgical resident is available as an operative sistant and a qualified anesthetist is available for giving the 'esthetic, the referring physician should not act in either ca- 'city, because this practice may encourage fee-splitting. Such tbterfuge is not necessary to justify adequate remuneration of n referring physician for his medical responsibility to the 'tient. However, in the absence of a qualified surgical resident anesthetist the practice of having the referring physician (not pecially trained in these functions) assist with the operation is )t considered unethical providing the referring physician sends s own bill. d. Payment of a salary by a medical clinic or physician to 'other physician, as compensation for referring patients to that inic or physician. e. The practice of accepting a rebate or commission from the large made by a company for material ordered from them for patient; this is considered unethical, and equivalent to fee-

Practices which are classified as undesirable, unethical, or fee-

a. The combined bill (itemized or not itemized) sent by a wsician to a patient is disapproved because either may be a bterfuge for fee-splitting. In bona fide clinics (whose members e on a pre-arranged salary or partnership basis) the combined 11 is approved. In hospitals where the medical staff has author- sd the hospital to send combined bills for physician services, eh bills are considered ethical if itemized. b. The insistence by some insurance companies of requiring at bills of more than one physician for medical services ex- uded a patient, be sent as one bill is highly undesirable. is recommended that the College of Surgeons contact appropri- e insurance companies recommending that if for their efficient 506 Fellowship of Surgeons operation, a single bill for the services of more than one physician is essential, then the bill should be itemized, and payment be made to each physician separately. MEANS OF COMBATING FEE-SPLITTING 1. On many occasions the general practitioner or referring physician is not getting "proper recompense" for his time spent in taking care of the patient initially, and his part in making the diagnosis. The American College of Surgeons strongly urges that the surgeon emphasize to the patient the great value of initial care (including the diagnosis), and likewise that the general practitioner or referring physician should be paid adequately by the patient for his services. 2. The American College of Surgeons condemns overcharging of the patient by the surgeon, on the basis that this practice is unjust. Moreover, it encourages fee-splitting because the patient's financial reserves are so depleted that the referring physician cannot be paid adequately for his medical services. 3. The public should be educated to the value of the referring physician's services. 4. Faculties of Medical Schools, Hospitals and Medical Societies should emphasize more strongly than previously the evils of fee- splitting to young physicians and surgeons in training and insist that they avoid this practice at all costs. 5. The membership of any Fellows known to be fee-splitters should be cancelled. 6. Within certain limitations, there should be encouragement of the policy, recently adopted, to have panel discussions on fee- splitting in our College Sectional Meetings. 7. The formation of Grievance Committees by County and State Societies should be encouraged by offering public support to the efforts of these groups. 8. The surgeons should be educated to the fact that the surgeon's fee should be limited by the patient's ability to pay, and the amount determined, in part, by other medical expenses. 9. The surgeon should consult more freely with referring physicians with regard to the patient's ability to pay. Frank discussion with the patient before services are rendered is highly desirable. 10. Except in bona fide clinics (whose members are on a prearranged salary or partnership basis), it is paramount that the patient be informed exactly as to the amount due and payable to each physician, when more than one physician has extended medical care to the patient. 11. The College reaffirms and reemphasizes its opposition to fee- splitting and recommends that this fact, along with efforts to combat the evil be publicized. Fellowship of Surgeons 507 12. It is recommended that the American College of Surgeons contact the National Association of Clinic Managers informing it that the College considers placement of practitioners of medicine on the part-time payroll of a clinic is a dangerous practice, and is purely a form of fee-splitting when payment is for referring patients to that Clinic. 13. When asked by a hospital staff for advice as to how fee- splitting may be corrected, the American College of Surgeons is encouraged to recommend as one of the mechanisms, that staff members be required to present a statement by a qualified public accountant showing that their financial records do not reveal evidence of fee-splitting in any form. 14. The American College of Surgeons encourages hospitals which are having difficulty with identification of the surgeon to have the patient or legal representative sign a properly witnessed operative permit, which clearly states the name of the surgeon who will perform the operation. 15. If the Board of Regents approves this report, the Committee recommends that a copy be sent to all members of the American College of Surgeons, and that members be assured the College stands ready to investigate signed written complaints of fee- splitting.

INDEX

Abbott, Amos W., 477 Blue Book, See Directory Abell, Irvin, 358, 361, 363, 385, 367, Board of Governors 373, 433, 448 Bylaws revision, 190, 204 Academy of Surgery, Philadelphia, 50 Duties, 281, 398-399 Adams, Samuel Hopkins, 119 Election of Officers, 164 Advisory Board for Medical Specialties, Homeopathy Representation, 145 341, 343, 406-407, 458 Importance of, 317 Allen, Arthur W., 318-319, 323, 359, Increase in members, 439-441 371, 373-375, 377-378, 381, 384, Neglect of, 359, 374 387, 397, 400-491, 403, 413, 417, Organization, 71, 81-89, 102, 106, 441 108, 126 American Academy of General Prac- Board of Regents tice, 383, 388, 412, 433, 453-454 Advisory Council, 401 American Academy of Ophthalmology Chairman, 280, 311, 373, 401, 403, and Otolaryngology, 194 442, 445 American Association of Obstetricians Executive Committee, 255, 317, and Gynecologists, 88, 106-107 319, 344 American Board of Anesthesiology, 395- Honorary Regents, 320 397 Joint Meetings with: American Board of Abdominal Surgery, American Boards, 365 457 American Hospital Association, American Board of Obstetrics and 381-382 Gynecology, 365-388 A. M. A. Board of Trustees, 381- American Board of Ophthalmology, 234, 365, 434 340, 365 American Society for the Con- American Board of Orthopedic Sur- trol of Cancer, 303 gery, 365 Clinical Congress, 189 American Board of Otolaryngology, 275, Liaison Committee, 446 278, 365 Meetings, 107-137, 143-149, 160, American Board of Surgery, 266, 341, 168, 172-173, 188, 198, 202, 347, 365, 371, 389-393, 411, 439 212, 257, 288-289, 321, 350, American Board of Urology, 365 355, 423-424 American Cancer Society, 119, 252, 274, Nominating Committee, 164, 283 276, 303, 328, 369, 447 Organization, 82-89, 93-95 American College of Physicians, 280, "Principles of Financial Relations 315, 356, 382-383 in the Professional Care of the American College of Surgeons Patient," 417 Administrative Affairs, 201, 233, 237, Public Relations Committee, 435 261, 344, 355-356, 367-368, 373, Trustees of the A.M.A. (Committee 414, 446 to Confer With), 435-436 509 510 Fellowship of Surgeons

Reorganization, 320-325 Clinical Research, 275 Reply to Criticism, 259-261 (Eclat), Fellowship, 446 293-295 (Graham) Literary Research, 233 Terms of Service, 293, 320, 400, Organization and Assembly, 446 440-441 Professional Services and Accredi- Visitors, 299 tation, 448 Bone Sarcoma Registry, 237-238, 251, Director, 148, 152, 160, 166-168, 201, 270, 273, 329 235, 239-240, 259 (Director-Gen- Cancer Campaign, 63-64, 118-119, eral), 323, 373, 375, 377-378, 157, 250, 247-78, 328, 446-447 389, 430, 437, 446 (Asst.) Cancer Clinics, 274, 276, 303-304, Directory, 74, 108, 439 328, 447 Dues, See Fees and Dues Cancer Detection Centers, 447 Endowment Fund, 148, 150-152, 160- Cancer Survey Program, 447 161, 165, 169-170, 185, 223, 226, Candidate Examination Committee, 241, 272, 279, 282, 331 145 Executive Committee, 70, 237, 255, Candidate School for Fellowship, 254- 261, 346, 446 255, 258, 262-263, 494 Expulsion of Fellows, 184, 266, 284, Catgut Suture Material Manufactur- 331 ing and Sterilization Committee, Fee-splitting, 87-88, 95-100, 111, 133, 356-357 135, 137-142, 162, 167-169, 171- Charter, 75 172, 184, 188-201, 206, 221-223, Committee on Committees, 81-82, 255-256, 258, 264, 266, 284, 290- 477-479 294, 331, 355, 362, 403, 413-414, Committee to Study the Treatment of 416-420, 435, 480, 503-507 Malignant Diseases with Radium Fees and Dues, 74, 102, 106, 108-109, and X-rays, 250, 328 175, 185, 223, 241, 331 Community Meetings, 283 Fellow of the American College of Constitution and Bylaws, 81-85, 106- Surgeons (F.A.C.S.), 93, 108, 109, 126, 184, 190, 204, 261, 155, 162 289, 317, 322, 359, 401, 440-441 Fellowship Convocations, 100, 113, 115, 127, Anesthesiologist problem, 367, 395- 130, 159, 165, 170, 198, 212, 397 221, 246, 270, 368 Applications for Fellowship, 83, 95, Credentials Committee, 84, 93-95, 98, 107, 109, 111, 115, 120, 124, 107, 109, 120, 124, 144, 149, 332 (Committee), 357, 359, 163, 399 (See also Fellowship 439 Requirements) Certificate, 170-171 Central, 107, 109, 111-112 Chicago Fellows, 227 Local, 316, 331-332, 449 Classes, 86, 110-111 State, 111, 260, 294, 316 Founder Fellows, 70, 82, 85-87, Criticism, 80, 89-93, 101-106, 113- 107, 112, 187 115, 130-133, 165, 187, 203, 219, Group Disability Insurance Pro- 246, 248, 256, 258-265, 279, 285- gram, 437 286, 289-301, 310, 317, 372, 388, Honorary Fellows, 113, 127, 199, 492-498 213, 290, 482 Declaration, See Oath Indiana Fellows, 311 Departments: Negro Fellows, 124-126, 332-333 Business and Finance, 446 New York Fellows, 183 Index 511

Requirements for Fellowship, 71, Junior Candidate Group, See Candi- 83-86, 94-95, 98, 100, 109- date School for Fellowship 112, 124, 143, 146-147, 149- Life Membership, 108, 279, 357 150, 160, 183, 234, 240, 260, Local Chapters, 272, 330, 367, 398 279, 347-348, 438, 449 (See (See also Sectional Meetings) also Credentials Committee) Medical Library, 223, 233, 270, 330, Finances, 74, 149-150, 161-182, 165, 356 168, 172, 179, 219, 233, 251, Medical Museum, 182, 270, 330 255, 259, 260, 269, 279 (Com- Medical Motion Pictures, 147-148, mittee), 282, 290-291, 294, 368, 190, 278, 330, 368, 372, 437 380, 384, 447 Medical Service Board, 307, 309, 363, Foundation for Clinical Research, 280 447 Founding, 57-58, 473-475 (Committee Meetings, See Convocations of Nine) Merger with Clinical Congress, 204, Fractures and Industrial Medicine 219, 488 Committee, 249-250, 276-277, Military Service, 191-192, 211, 381, 329 366-367, 376 General Hospital Committee, 208 Oath, 96-98, 111, 480 (See also Gifts, Grants and Bequests, 118, 176, Pledge) 180, 227-228, 230, 269, 280-281, Officers, 83, 88, 164 438 Organization, 58, 60-94, 101, 475 Governors, See Board of Governors Organization Meetings, 70, 72-78 Graduate Training for Surgery, 61, Permanent Home, 123-124 (Commit- 69, 74, 81, 88, 133, 137, 143, tee), 144-145, 148-152, 160-163, 153, 242-244, 254, 355 (Commit- 177-184, 200, 215, 224, 229, 233, tee)-349, 360, 369, 389, 391-395, 282, 484-485 439 Pledge, 126, 171, 222-223, 254, 481 Great Mace, 234, 491 (See also Oath) "Hands We Trust," 460 Post-graduate and Research Work Hospital Graduate Training Program, Committee, 242 380 President, 88, 185, 190, 218, 231, 245- Hospital Laboratories (Standards for), 248, 283, 440 251, 277 (Committee)-278 Professional Relations Committee, 418 Hospital Radiological Equipment Progress Review, 327-333 (Committee for Elevating the Proselyting, 256-266 Standards for) 278 Publicity, 169, 260 (Committee) Hospital Standardization, 83-64, 70, Regalia, 105-106, 113, 130, 143 116-118, 152, 157-158, 172-176, Regents, See Board of Regents 185, 187, 190, 205-208, 210-222, Residencies, See Graduate Training 230, 239-240, 245, 272, 290, 311, for Surgery 327, 360, 364, 368, 372, 379-395, Resignations, 223, 227, 287 (See also 443-445, 476, 489, 500 Expulsion) Hospital Survey, 157, 207, 240, 272 Scholarships, 437-438 Ideals and Aims, 61-62, 70, 73, 82, Secretary-General, 83, 202-204, 240 88-89, 473-474 Sectional Meetings, 223, 252-253, 302, Incorporation, 70, 82, 478 367, 481 (See also Local Chap- Industrial Medicine and Traumatic ters) Surgery (Board) 277 South American Affiliations, 178, 231- Industrial Surgery Committee, 232 232, 253-254 512 Fellowship of Surgeons

Standardization of Surgeons, See Judicial Council, 88, 135, 142, 305- Graduate Training for Surgery 306, 427, 451 Surgical Forum, 190, 368 Meetings, 18, 20, 93, 148, 169 War Session Programs, 368 President, 44, 66, 358 American Conference on Hospital Serv- "Principles of Medical Ethics," 142, ice, 222, 230-231 448 American Cyanamid Company Surgical Section on Obstetrics and Diseases of Products Division, 437 Women, 15, 20 American Federation of Labor, 232 Section on Surgery, 79, 86, 152, 336 American Gynecological Society, 29, American Medical Editors' and Authors' 107, 118, 191 Association, 352 American Hospital Association, 117, American Medicine, 91, 113 157, 185, 201, 206, 327, 381-387 American Nurses Association, 357 Council on Professional Practices, 382 American Society for the Control of Division on Nursing, 357 Cancer, See American Cancer So- American Hospital Conference, 230-231 ciety American Institute of Homeopathy, 145, American Society of Anesthesiologists, 160 395, 397 American Journal of Obstetrics, 28 American Surgical Association, 13, 29, American Medical Association, 28, 73, 78-79, 84, 104, 112, 243, 257 104, 117, 123, 132-133, 135, 137, Anderson, Donald G., 392, 501 145, 155, 157, 170, 177, 180, 198, Andrews, Edmund, 10 216, 327, 359, 384 Andrews, E. Wyllys, 5, 94, 115, 256, Board of Trustees, 87-88, 135, 158, 477, 492 208, 215, 218, 231, 312-313, 361- Andrus, William D., 393 362, 385, 383, 408, 415, 453 Anesthesia, 31, 139 Bureau of Medical Economics, 305, Anglo-American Pharmaceutical Co., 498 39 Council of Medical Economics, 305, Animated Illustrations 278, 372 498 Antisepsis in Surgery, 10, 31, 139 Council of Health and Public Instruc- Archibald, Edward W., 336 tion, 118 Apostoli, Georges, 13 Council on Constitution and Bylaws, Argentina Surgical Society, 254 438 Armour, J. Ogden, 228 Council on Industrial Health, 358 Armstrong, George E., 89, 129, 231 Council on Medical Education and Army Reserve Medical Corps, 191 Hospitals, 33, 152, 175, 205, 208, Ashhurst, John, Jr., 31n 216, 230 (and Hospitals), 338, Ashton, William, 46n 340-341, 346, 356, 360-361, 365, Association of American Medical Col- 383, 385, 389-390, 392-395, 405, leges, 346-348 458, 464 Association of Railway Chief Surgeons, Directory, 42, 458 232 Foundation, 138 House of Delegates, 80, 131, 186-187, Babcock, Wayne, 51 197, 215, 230, 305, 309-310, 319, Bachmeyer, A. C., 381 363-364, 383, 385-386, 388, 431- Bacon, Asa S., 208 433, 447, 453, 469, 495-496 Bacon, Charles S., 5, 94 Journal, 4, 21, 104, 134, 141, 354, Baird, Alvin W., 477 363, 384, 409, 429 Baker, Joel W., 418 Index 513

Baker, Newton, 192, 214 Brown, John Young, 207, 478 Baldy, J. Montgomery, 46n, 49, 465 Bruce, Herbert A., 84, 89, 121, 145, Ballou, Albert D., 32n, 41, 43, 45n, 147- 163, 478 148, 155, 326, 370 Buerger, Leo, 55 Baruch, Bernard, 193 Buffington, Eugene J., 228 Bastianelli, Raffaele, 213 Bugbee, George, 381 Beclare, Henri, 213 Bunts, Frank E., 478 Beecher, Henry K., 396 Bureau of Internal Revenue, See Inter- Belfield, William T., 37n nal Revenue Bergen Evening Record, 425 Burling, Edward, 490 Besley, Frederic A., 4-6, 27, 63, 275, Butter, E. B., 228 349, 355, 476, 498 Byford, Henry T., 478 Bevan, Arthur Dean, 12, 33, 42, 126, 175, 197, 199, 208-211, 213-214, Caldwell, Guy A., 393, 501 216, 219, 256, 259, 287, 366, 370, California Medical Association, 415 403, 463, 464 California State Medical Journal, 80, 89, Bierring, Walter, 312, 314, 498 114, 130, 401 Billings, C. K. G., 463 Canadian Medical Association, 88, 117, Billings, Frank, 8, 12, 42, 99, 142, 215, 136 (Journal), 348, 385 230, 463 Carbolic acid spray, 10-11, 31 Binnie, J. F., 50, 477 Carnegie Foundation for the Advance- Blake, Joseph E., 112, 119, 200 ment of Teaching, 33, 116, 144, Blanchard, R. J., 477 157, 166-167, 176, 230 Bland-Sutton, Sir John, 30, 157 Carr, Walter E., 200, 244, 269 Bloodgood, Joseph G., 157, 170, 238, Carrel, Alexis, 199 251, 255, 258, 262-263, 273, 477 Cary, E. J., 498 Blalock, Alfred L., 393 Case, James T., 278 Blue, Rupert, 198 Cassels, Kennedy, 461 Blue Cross-Blue Shield, 309, 377, 381, Catholic Hospital Association, 208 449, 450n, 451-452 Cave, Henry W., 333, 398 Bornemeier, Walter C., 417, 419 Cheever, David, 299 Boston Globe, 425 Chicago Association of Commerce, 227 Boston Herald, 317 Chicago Daily News, 427 Boston Transcript, 120 Chicago Examiner, 131 Bovee, J. Wesley, 477 Chicago Gynecological Society, 13, 15, Bowen, Margaret, 3-4, 28, 41 29 Bowlby, Anthony, 200 Chicago Medical College, 4, 9, 12, 21- Bowman, John G., 166-176, 190-195, 22, 463 197, 200-222, 228, 235-237, 489 Chicago Medical Journal and Examiner, Boy Scouts, 329 11, 28 Bradley, Omar, 376 Chicago Medical Society, 11, 14, 37, Braisted, William C., 198, 215 130 (Bulletin), 131, 135, 140, 417, Brewer, George E., 50, 53, 63-64, 70, 426-427 75, 78, 89, 112, 119-120, 125, 159, Chicago Record-Herald, 131 184, 188, 475, 484 Chicago South Park District, 225 Briclmer, Walter M., 101-102 Chicago South-Side Medico-Social So- Brinsmade, William B., 477 ciety, 12-13, 16-17, 33, 42, 197, Broun, Le Roy, 52, 53n 483 Brower, R. D., 11, 13 Chicago Sun-Times, 426 514 Fellowship of Surgeons Chicago. State Street Retail Stores Asso- Treasurer's Report, 469-470 ciation, 228 Clopton, M. B., 267-268 Chicago Surgical Society, 213 Code of Hammurabi, 137 Chicago Symphony Orchestra, 23 Codman, Ernest A., 116, 147, 157, 172- Chicago Tribune, 129, 158 174, 207, 237-238, 248, 251, 263, Chipman, W. W., 63-64, 88, 127, 133- 272-273, 476 134, 163, 270, 282, 439, 475-476 Coffey, Robert E., 478 Chown, H. H., 478 Coffey-Humber Treatment of Cancer, Church, Archibald, 8 275 Me Clinic, 436 Cole, Warren H., 393, 418, 460 Clark, John G., 45n, 46-47, 73-74, 189- Coller, Frederick A., 243, 371, 381, 393, 190, 242, 335, 476, 478 501 Clinical Congress of Surgeons of North Collier's 119, 433 America Colorado Medicine, 135 Constitution and Bylaws, 59-60, 472- Co1p, Ralph, 418 473 Columbia University, 166, 208 Executive Committee, 60, 465 Colwell (A.M.A.) 219 Finances, 48-49, 57, 60, 115, 157, Committee of American Physicians for 465-466 Medical Preparedness, 191 Founding, 39-45 Committee on the Cost of Medical Care, Ideals and Aims, 61, 261-262, 330, 304-305 335 Compere, Edward L., 455 Medical Student Guests, 454-455 Conference Committee on Graduate Membership Limitation, 60 Training in Surgery, 393-395 Meetings, 42-49, 52-56, 71, 100, 113, Continental National Bank and Trust 115, 118, 128-129, 147-148, 155- Co., 282 159, 197-198, 202, 207, 212, 221, Contract Practice, 358 278, 284, 287, 316-317, 321, 323, Conzett, Donald, 424 360, 367-369, 372, 399, 435-436, Cook County Hospital, Chicago, 21, 460 27, 30, 464 Merger with American College of Sur- Cornell Clinic, 305 geons, 187-190, 488 Corrigan, Francis P., 253-254 Moving Pictures, 278 Cotton, Frederic, 65, 76-77, 89, 94, 98, Official Call for Meeting to Found 107, 109, 112, 124, 189, 202, 284, A. C. S. 475, 485 President, 50, 53, 60, 62-63, 190 Council of National Defense, 367 Press reports, 50-52 Craig, Allan, 253 Registration Fee, 48, 60 Crile, George W. Representatives, 59 Biography, 68 Resolutions (Martin) 61 Board of Regents, 89, 107, 109, 119, Secretary's Report, 466-470, 473 127, 134, 202, 218, 280 (Ch.), Sectional Meetings, 223, 253, 267, 291, 313-314, 319, 322-323, 344, 330 346, 349, 355-357, 363, 366 Symposium for Discussion of Medical (Resignation), 403 and Surgical Economics, 305 Cancer Treatment Committee, 275n Symposium on the Curability of Can- Controversy (A.C.S.-A.M.A.) cer, 328 Credentials Committee (Regional) 163 Television use, 437 Criticisms (A.C.S.) 293 Title, 45 Endowment Fund, 150, 165 Index 515 Hall of Art and Science of Surgery, Donnelley, R. R., 4, 8, 28 330 Donnelley, Thomas E., 4-5, 26, 179 Hospital Laboratories, 251 Downing, W. L., 422 Medical Library and Museum, 225, Draper, Warren F., 429, 449 233, 237, 330 Dukes, Charles, 498 Merger (A.C.S.-C.C.), 188 Dunott, Daniel Z., 232 Oath, 97-98 Durham, Arthur, 31n Organization (A.C.S.), 477 Duval, Pierre, 213 Permanent Home (A.C.S.), 145, 180, 225 Eagleson, James Beaty, 44, 78, 478 President, 185 Early Medical Periodicals, 27 Royal College of Surgeons of Eng- Eastman, Joseph, 20 land, 105-106 Eastman Kodak Co., 278 Society of Clinical Surgery, 33 Eclat Society, 257-258, 262, 293, 325, War Wound Treatment (Keen), 200 340, 412-494 Crosby, Edwin L., 287 Eisenhower, Dwight D., 405, 442 Cromwell, Bowman C., 273-275, 325- Electricity in Surgery, 15, 274-275 326, 355, 363n, 373, 499 Eliot, Ellsworth, Jr., 53 Crozier, Frank, 6, 225 Ellis, H. Bert, 478 Cubbins, William, 4-6, 24, 27, 463 Elting, Arthur W., 257, 262, 342 Cullen, Thomas E., 478 Endicott-Johnson Co., 305 Cullen, Thomas S., 63, 118-119, 157, Erdman, John F., 53 253, 447 Ernest Reckitt and Co., 259 Cushing, Harvey, 33, 38, 76, 97, 105, Estes, William L., Jr., 398 117, 200, 246-248, 261 Eve, Frederick, 483 Cutler, Elliott C., 286, 297, 336, 353 Ewing, James L., 238, 251, 273 Cutter, Irving S., 286 Cutter, W. D., 356, 361, 364-365 Farrand, Livingston, 123 Farrow, Marion T., 326, 498 Da Costa, John Chalmers, 38, 75 Fenger, Christian, 24-25 Dakin, H. D., 199 Fieder, A., 490 Dakin's Solution, 200 Finley, Charles 0., 437-438 David, Vernon C., 323 Finney, John M. T. Davis, Edward P., 46n, 465 Biography, 52, 65-66 Davis, Loyal, 428-427, 460 Board of Regents, 119 (Ch.), 320 Davis, Nathan Smith, 4, 9-10, 18, 22, 28 (Honorary) Davis and Geck, See American Cyana- Committee of Nine, 475 mid Co. Fellowship, 107-112, 122-129, 144, Deaver, John B., 50-51, 243, 248, 335, 149, 183-185 465 Hospital standardization program, 207 De Quervain, 353 Merger, 159, 188 Derele, Col. C. U., 198 Military affairs, 192, 212 De Schweinitz, George E., 46n, 485 Murphy Memorial, 233, 244 Deutsch, Albert, 415 Organization of A.C.S., 72-73 Dichloramine-T, See Dakin's Solution President of A.C.S., 88, 91 Dickinson, Robert L., 53n, 478 President-Elect of A.M.A., 215 Directory of Medical Specialists, 458 Resignation, 332 Doering, Edmund J., 12-13, 464 Term of Office, 293 Doheny, Edward, 179 Firor, Warfield M., 313, 390, 501 516 Fellowship of Surgeons Fishbein, Morris L, 354, 363, 408 Halsted, William Stew Fisher, Lucius, 226, 490 127, 137, 143, 482 Fleeter, Abraham, 33-36, 147 Hamann, C. A., 478 Foss, Harold L., 335, 396 Harper's, 271, 305 Fox Movietone Co., 278 Harris, Malcolm L., 21L1 Franklin H. Martin Memorial Founda- Harvard Medical Schoo tion, 371 Harvey, Samuel C., 29' Frazier, Charles H., 48n, 465 337, 347-348, 371, French Army Medical Corps, 198 Hatfield, John, 381, 38 Frick, W. J., 478 Hawley, Paul R., 375-3i 407, 409-411, 42C Genie, W. Edward, 418 431, 433, 435, 431 Cask, George E., 213 460-461 Gaub, Otto C., 478 Hays, Will, 278 Cellhorn, George, 478 Health Inventoriums, 2 George, Milton, 387 Healy, John J., 387 Cerster, Arpad, 53n Health Insurance Plan. Ghost Surgeons, 416, 418 444 (See also I Gibbon, John H., 46n, 51, 75, 465 Shield, and Hos Gibbons, James Cardinal, 207 Plans) Codlee, Sir Rickman, 106, 113, 127, 129, Hearst, Mrs. William I 482-483,491 Heinbecker, Peter, 393 Goldspohn, Albert, 6 Hektoen, Ludwig, 251 Gompers, Samuel, 232 Henderson, Elmer L., 3 Goodrich, Annie W., 208 Herrick, James B., 12, 4 Godwin, Thomas H., 198 Heuer, George J., 256, Gorges, William, 192, 214-215 492 Gossard, H. W., Co., 38 Hickey, Preston M., 278 Graham, Everts A., 286-301, 319, 336, Higgins, Charles C., 39 340, 342-344, 366-367, 371, 385, Hippocratic Law and

387, 403-404, 406, 408, 410-414, Hirst, Barton Cooke, 46 : 434, 440-442, 458 Hobby, Oveta Culp, 44f: Green, William, 232 Hollister, John C., 4-6, Greenough, Robert B., 119, 250, 273, Hollister, John H., 3, 15 307, 309, 313-314, 318-319, 324, Holmes, R. W., 5 347, 363, 498 Hopkins, John P., 225 Crigsby-Grunow Co., 275, 281 Hornsby, John A., 207 Grimm, Eleanor K., 498 Hospital Insurance Plan Gross, Samuel, 79-80 318,449 (See also Grunow, William C., 280-281, 285 Shield, and Health Gunderson, Gunnar, 386-387 Hospital Tissue Comm Gunn, Moses, 463 Hospitals, Approved, 2: Hoyne, Maclay, 228

Haggard, William D. , 89, 96, 124-126, Hummel, Stuart K., 389 335, 365 Hunt, Harold Lyons, 35 Hall of the Art and Science of Surgery, Hunterian Museum, 1& 330 Huntington, George S., Halpenny, Jasper, 478 Huntington, Thomas W. Halstead, Albert E., 478 Hurley, E. N., 233 Index 517

Hurley, Edward, 179 Judd, E. Starr, 256, 492 Hutchison, James A., 478 Kanavel, Allen B. Illinois Medical Journal, 132 American Board of Surgery, 341 Illinois State Medical Society, 27, 135 Bibliographical, 27, 358 (Death) Indiana Medical Association, Journal, American College of Surgeons 496 Board of Regents, 323 (Vice-Ch.), Influenza Pandemic, 213 349-355 Intern Training, 241-242 Graham Criticism Answer, 298-300 Internal Revenue Bureau, 421, 435 Hospital Standardization, 157, 207, International Abstract of Surgery, 59 311-313, 335, 478 International Board of Surgery, 406, Reorganization, 319-321 409, 455, 502 Treasurer's Report, 465, 469-470, International College of Surgeons, 350- 478 355, 406-413, 455, 502 Clinical Congress, 48, 62-63 International Federation of Surgical Col- "Infections of the Hand" film leges and Societies, 460-462 Military Service, 203 International Journal of Surgery, 353 Surgery, Gynecology and Obstetrics, International Medical Congress, 17, 105 4-8, 29n, 32, 38, 48, 271 International Society of Surgery, 352- Keen, William Williams, 31n, 113, 127, 354, 409 200, 482 International Symposium on Cancer, 274 Kellogg Foundation, 436 Iowa City Daily Press, 166 Kelly, A. D., 387 Iowa State Medical Society, 104, 167, Kelly, Howard, 20, 24, 275 422-423, 435 Kemper Foundation, James S., 438 Iowa State University, 166-167, 171 Kendall, Edward C., 185-187, 487 Ireland, Merritt, 213 Keyes, E. L., Jr., 53, 275 Kickbacks, See Rebates Jackson, Jabez N., 478 King, James E., 317 Jenkins, Hflger P., 437 Jenks, Edward W., 12 Jennings, John E., 272 Lambert, Alexander, 215 Jentzer, Albert, 352 Lancet, 156 John B. Murphy Memorial, 179-183, Lahey, Frank H., 292, 297, 318, 343 200, 225-227, 233, 244, 269-270, (Clinic) 485-487 La Place, Ernest, 51-52 Johns Hopkins Medical School and Hos- Larson, E. Eric, 418 pital, 20, 118, 137, 143, 185, 391 Larson, L. W., 387 Johnson and Johnson, 38, 369, 372 Le Conte, Robert G., 46n, 50, 75, 84, Joint Commission for the Accreditation 465, 478 of Hospitals, 387-388, 436 Lee, Burton J., 257 Joint National Committee on the Eleva- tion of Standards of the Practice of Leigh, Southgate, 63 Surgery, 336-337 Leveroos, Edward, 393, 501 Jones, Philip Mills, 80, 89-90, 93-94, Lewis, Dean, 94, 256-258, 352, 492 101-105, 113-115, 130, 412 Lewis, H. Edwin, 91 Journal of the American Medical Asso- Lewis, Henry F., 130 ciation, See American Medical As- Lewis, J. Hamilton, 359 sociation. Journal Lilienthal, Howard, 53 518 Fellowship of Surgeons Lilly, Thomas, 421 Martin, Franklin H. "List" practice, See Contract Practice American College of Surgeons Lister Technique, 10-11, 13-14, 20 Board of Regents Revision, 320-321 Littell, Norman, 407-408, 455 Chicago Surgical Society Dinner, Local Advisory Committee on Graduate 213 Training in Surgery, 344 Credentials, 93-96 Logan Frank, 228 Cushing Letter, 246 Long, John Wesley, 84, 162-163, 252, Director General, 259, 322 (Hon- 254-255, 262 orary) Los Angeles Better Business Bureau, 415 Eclat Society, 256-257 Los Angeles County Medical Associa- Endowment Fund, 145 tion, 415 Fellowship, 94-106, 108-112, 121, Lull, George, 408 160 Lund, Fred B., 189-190 Founding and Organization, 57-88, Lynch, Frank W., 275 235 Lyon, E. K., 387 Fund Raising, 227-229, 280 Lyon, E. P., 208 Hospital Laboratories, 251 Hospital Standardization, 63, 215- McAmmond, E. N. C., 457 219, 263, 348 McArdle, John Stephen, 30 Industrial Surgery, 232 McArthur, Lewis L., 12, 464 Medical Economics, 304, 308, 316 McClure's, 119 Murphy Memorial, 178-182, 233, McIntire, Ross, 498 244, 269 McIntosh Galvano-Faradic Co., 13 Permanent Home, 123, 144-145, McKechnie, Robert E., 78, 89, 293, 478 152, 177, 224-226, 282 McMurtry, Lewis, 478 President, 283 MacCallum, W. G., 55 Regalia, 113 MacEachem, Malcolm, 245, 264, 325, Resignation (Proposed) 122, 144 327, 342-345, 347-348, 355-356, Revisions and Changes, 319-321 361-362, 364-365, 373-374, 382, Retirement, 321-325 417, 501 Secretary-General, 302 MacKenzie, K. A. J., 478 Sectional Meetings, 252 MacLaren, Archibald, 478 South American Candidates, 231- MacLean, Donald, 31n 232, 353 Macy Foundation, Josiah, Jr., 364 Surgery Standardization, 33, 36-37, Macrae, Donald, 255 39-40, 61-62 (Resolutions), 139, Magnuson, Paul B., 414 194-195, 242, 265, 286-301 Majestic Radio, 280 Biographical, 8-30, 326-327 (Death) Makins, G. H., 483 Cancer Research, 26n Clinical Congress, 39-43, 45-49, 53, Mallory, Frank M., 251, 273 55-61, 147, 159, 212, 222-223, 465 Malpractice Suit Insurance, 357 Criticism (Personal), 105, 203, 214- Markoe, J. W., 53n 215, 256, 260, 279, 298, 317-318 Marlowe, Frederick W., 478 (Boston) Martin, Edward, 46n, 53, 58-70, 73, Electricity in Surgery, 15, 275 75, 81-89, 94, 109-113, 116, 143, Expenses (Personal) 166, 200 145, 150, 157, 159-160, 179, 188- Gibbons' audience, 207 190, 202, 207, 272, 321, 365, 465, Head Injury, 302-303 475-476 Illness, 202 Index 519

"Joy of Living," 75n, 463, 491 "Medical Education in the United States Medical Education, 8-12, 22 and Canada" (Flexner Report) 33- Military Affairs, 192-198, 203, 214- 38 215 Medical Ethics, 133, 139, 165, 166, 413- Politics, 14, 17, 19, 23-24, 193, 302 436, 440, 454, 503-507 (See also, Press, 120-121 Fee-splitting, Ghost Surgeons, Re- Private Practice, 12-14, 16, 23, 165- bates) 166, 198, 203 Medical Journalism (Early), 4, 27 Recreation, 18, 23 Medical Licensure, 57, 111, 115, 142, Reminiscences of, 346, 348, 355, 375, 242, 340, 444 442, 462 Medical Service Board, 307-308, 358, Surgery, Gynecology and Obstetrics, 363, 496 3-8, 26, 39, 47-48, 147, 165, 224, Medical Society of the County of New 270-271 York, 424 Travel and Vacations, 20, 39, 224, Medical Standard, 28 231, 302, 325-326, 353 Meleney, Frank L., 357 Ureter Transplantation, 23-25 Mercy Hospital, Chicago, 10, 12, 18, 21 Uterine Fibroids, 19 Methodist Board of Hospitals, Homes Will, 333, 370 and Deaconess Work, 207 Martin, Isabelle Hollister, 3-4, 6, 14-28, Meyer, Willy, 53n 39-40, 49, 52, 64-68, 106, 193, 202- Michael Reese Hospital, Chicago, 21 203, 271, 302, 333-334, 370 Michigan State Medical Society, Journal (Death) 104, 135 Martin Memorial Lecture, 371 Middleton, William S., 387 Maryland Medical Society, 119 Midlothian Country Club, 4, 25 Marvel, Emery, 120n Miller, C. Jeff, 63, 324, 341 Mason, James M., 333, 398 Miller, George H., 501 Massachusetts General Hospital, Boston, Minnesota. University, 186-187 305 Minor Surgery, 453 Matas, Rudolph, 65-67, 88, 110, 133, Mississippi Valley Medical Association, 160, 163, 188, 335, 351, 355, 409, 37, 469 475 Missouri Medicine, 411-413 Matthews, James D., 478 Mitchell, John J., 228 Mayer, Leopold, 353 Mitchell, Weir, 11 Mayo, Charles H., 67, 78, 81, 89, 96- Modern Hospital, 207 99, 105, 119, 150, 157, 168, 171- Moore, James E., 478 172, 180, 186, 188-189, 199, 258, Morison, James Rutherford, 30 275, 283, 291, 283, 297, 320, 322, Morris, Robert, 53n 333, 475 Moulinier, Charles B., 206, 208 Mayo, William J., 33, 67, 78, 105, 134, Moynihan, B. G. A., 30, 37,199-200 186-187, 190-191, 202, 215-219, Mumford, James G., 33 226, 228, 231, 247, 253, 271, 286, Munroe, Alex R., 286 299, 320, 322, 335, 476 Murphy, Fred T., 478 Mayo Clinic, 213, 343 Murphy, John B. Mayo-Robson, A. W., 30 American College of Surgeons, 58, Medical Audits, 421, 438 64-66, 69-70, 77, 89 (Regent), Medical Economics, 304-316 98-100, 105-106, 109, 123, 125, Medical Education, 9, 31, 33-36, 241- 131, 141 (Rebates), 145, 151, 243, 443 168, 475 520 Fellowship of Surgeons

American Medical Association, 44, 80 Northern Trust Co., 282 (President) Northwestern University Medical Chicago South-Side Medico-Social School, 21-22, 27, 197, 464 Society, 463-464 Nursing Education, 358 Clinical Congress, 45, 62, 91, 129, 157, 159, 188, 190 Obstetrical Society of Philadelphia, 26, Criticism (Personal), 114 50 Death, 177, 224 Ochsner, Albert J., 8, 44-45, 50, 58, 65- Northwestern University Medical 66, 68, 70, 85, 88, 94-95, 98, 100, School, 197 107-112, 120, 124-126, 129, 149, Oratory, 20-21, 150-151 159, 161, 163, 179, 188-190, 218, Society of Clinical Surgery, 33 226, 228, 258, 279, 475 Surgery, Gynecology and Obstetrics, Ochsner, Alton, 299, 323, 424 4-5, 8, 30, 38 Operations, Unjustified, 429 Murphy, Mrs. John B., 106, 178-180, Orr, Thomas G., 418 226, 233, 244, 269 Oswaldo Cruz Institute, 273 Murphy Clinic, 43-44 "Outline of the Treatment of Fractures," Murphy Memorial, See John B. Murphy 277 Memorial Murphy Oration, 290, 294 Pacific Coast Surgical Association, 337, Myles, Sir Thomas, 213 343 Paddock, Charles E., 6 Naffziger, Howard C., 294, 296, 348, Painter, Charles F., 478 365 Palmer, E. Payne, 118 National Advisory Council on Medical Pancoast, Henry K., 278 Education, 364 Park, Roswell, 112, 120 National Board of Medical Examiners, Parke, Davis and Co., 38 234, 340 Parsons, Willard, H., 399 National Cancer Institute, 369, 447 Patton, James, 228 National Committee for the Elevation Pearl, Raymond, 376 of the Standards of Surgery, 336- Pearson, William W., 219 337, 340, 343 Peck, Charles H., 53, 76, 251, 478 National League of Nursing Education, Pediatric Society of Philadelphia, 50 357 Pember, John E., 317-318 Neurological Society, Philadelphia, 50 Pennsylvania State Medical Society, 449 New England Surgical Association, 343 Pennsylvania, University, 445 New Willard Hotel, Washington, D.C., Peterson, Reuben, 478 71, 81 Phemister, Dallas B., 273, 299-300, 360, New York Academy of Medicine, 142 370, 501 New York Medical Journal, 102 Philadelphia County Medical Society, 50 New York Times, 103, 314-315 Philadelphia Inquirer, 51 Nicholas Senn Hospital, Omaha, 255 Philadelphia Press, 50 Nickerson, Samuel, 226, 490 Philadelphia Record, 51-52, 152 Nissen, Rudolf, 413 Philpott, Newell W., 387, 437 Norby, Joseph G., 381 Pick, John F., 352 North American, 51 Pilcher, Lewis S., 53 North American Practitioner, 17, 26, 28 Pilcher, Paul M., 478 North Pacific Coast Surgical Associa- Pittsburgh University, 235 tion, 84 Platt, Sir Harry, 461 Index 521 Polak, John 0., 53n Royal College of Surgeons of Edinburgh, Policlinic Hospital, Chicago, 3, 12, 16- 73 17 Royal College of Surgeons of England, Pool, Eugene, 348 73, 105-106, 115, 127, 234, 460, Porter, Charles A., 478 482 Porter, Miles Fuller, 86-88, 97, 126, 219 Royal College of Surgeons of Ireland, 73 Post-Graduate Medical School and Hos- Rush Medical College, 12, 21-22, 197, pital, Chicago, 34, 17-18, 21-22, 463-464 28, 36 Postgraduate Medicine, 408 Sachs, Edward, 275 Price, Julian P., 387 St. John, Fordyce, 371 Pritchett, Henry S., 33, 176 St. Joseph's Hospital, Chicago, 11 Proprietary Medical Schools, 22, 27, 31 St. Luke's Hospital, New York, 208 Proration, 450-451 Salisbury, Edward I., 253-254 Protestant Hospital Association, 207 Saturday Evening Post, 415 Public Education, 248, 252-253 Saunders, W. B. Co., 38, 200 Sayre, Donald Guthrie, 347 Rappleye, Willard C., 364 Schenck, B. R., 478 Ravdin, I. S., 397, 418, 445-446, 453, Schmidt, Erwin R., 299, 347 455, 460-461 Schroeder, William E., 6 Reader's Digest, 415 Scudder, Charles L., 249, 276 Rebates, 415, 419, 421 Seelig, Major G., 475 Red Cross, 329 Senn, Nicholas, 6, 8, 28, 30, 31n, 37, Reed, Walter, 25 463 Regents, See American College of Sur- Shannon, James S., 370 geons, Board of Regents Sharples, C. W., 478 Residencies, See American College of Shepherd, F. J., 478 Surgeons, Graduate Training for Shepherd, William G., 271 Surgery Sherk, Henry H., 478 Richardson, Maurice H., 50 Sherman, Harry, 77-78, 89, 93, 98-99, Ridlon, John, 131 114, 163, 169, 478 Ries, Emil, 38 Shurly, Burt R., 357 Rixford, Emmett, 67, 77, 81, 475 Silverthorn, G., 478 Roberts, John B., 46-47, 465 Simmons, George, 135, 213 Robinson, F., 37n Simonds, James P., 275 Rockefeller Foundation, 353 Simpson, Frank F., 63, 159, 191-192, Rodman, Stewart, 371 218, 478 Rodman, William L., 46n, 50, 158, 465 Sims, J. Marion, 13 Roeder, C. A., 255 Sloan, Le Roy H., 387 Roosevelt, F. D., 302-303, 306, 316, 361, Slobe, Frederick W., 240 Smith, Richard R., 478 498 Smith, Winford, 185 Rosenau, M. J., 251 Smith, Kline and French, 437 Rosenwald, Julius, 192, 227-228 Smithies, Frank, 137, 138n Rourke, A. J. J., 387 Social Security Board, 316 Royal College of Physicians and Sur- Socialized Medicine, 306, 498 geons of Canada, 438 Society for the Prevention of Cruelty to Royal College of Surgeons of Austral- Animals, 23 asia, 282 Society of Clinical Surgery, 32-33, 39- 522 Fellowship of Surgeons 40, 42, 256, 291, 293, 340, 492 Surgical Privileges, 453-454 Sommer, Ernst A., 78 Surgical Publishing Company of Chi- South America, 271, 285 cago, 6, 32, 37, 47, 57, 271, 282, South Side Dispensary, 14 326, 333, 370-371, 465 South-Side Medico-Social Society, 12- Surgical Society of Columbus, Ohio, 14, 16, 42 416-417 Southern Gynecological and Surgical As- Surgical Specialties, 69, 86, 193-194, sociation, See Southern Surgical 308, 336, 340, 389, 395, 439, 440 Association (Advisory Councils) Southern Surgical Association, 70, 86, Swift, Louis F., 228 337, 343 Symposium on the Curability of Cancer, Specialty Boards, 438 (See also Ameri- 328 can Boards) Squier, J. Bentley, 53, 59, 76, 251, 258, Tait, Lawson, 14, 20 279, 324, 335, 439 Taylor, Howard C., 53, 63, 478 Stephens, Harold M., 239-240, 255-256 Television, 190, 372, 437 Stewart, George David, 53, 55, 219 Tennessee State Medical Association. Stiles, Harold J., 30 Journal, 103 Stitt, E. R., 251 Thomas, Gilbert, 398 Stokes, Charles F., 89, 127, 144, 163, Thorek, Max, 352, 355, 409-412 178, 478 Thyroxin, 185-187, 487 Stone, Harvey B., 347, 393, 501 Time, 409 Strawn, Silas, 225 Tinker, Martin, 275 Sullivan, Roger, 225-226 "Treatment of War Wounds" (Keen), Surgery, Gynecology and Obstetrics 200 Advertisements, 38-39, 200 Truax Co., Chicago, 17 Building, 270 Truman, Stanley R., 387, 433-434 British Empire Number, 30 Turner, G. Gray, 213 Business and Finance, 6, 29, 41-42, 57, 465-469 United Mine Workers of America, 429, Cancer Symposium, 274 448 Clinical Congress, 39-46, 53-55, 57, U. S. Army, Medical Corps, 192 60, 147, 187, 468 U. S. Council of National Defense. Ad- Editorial Staff, 5-6, 30, 78 visory Commission, 192-193, 197- Founding and Organization, 3-8, 26- 198, 203, 214-215, 227, 232 30, 177 U. S. Department of Health, Education Franklin H. Martin Memorial, 334- and Welfare, 443 371 U. S. Government, 329 International Abstracts, 59 U. S. News and World Report, 430, 435 Medical Education, 37 Urological Surgeons, 279 Office, 165 Official Organ of Clinical Congress, Van Lennep, William B., 465 60, 224, 334 Vaughan, George Tully, 479 Prize Records, 279, 357 Vedder, Beverly, B., 408 Publication, 28 (First Issue), 29 Veterans Administration, 376, 380-381 (Single Issue Sponsorship) Vietor, Agnes C., 280 Subscriptions, 29, 38, 47 Volunteer Medical Service Corps of the Surgical History in the U. S., 31 U. S., 198-199 Surgical Insurance, 451 Von Bachelle, Cecil, 5

Index 523 Wagner-Doughton-Lewis Bill, 316 Wilson, W. W., 192, 195-197, 213-214, Waldorf-Astoria, 53, 58, 143 224 Walker, John B., 278 Wolbach, Bert, 251, 273 Wangensteen, Owen, 367 Woman's Home Companion, 415 Warren, J. Collins, 113, 127 Woman's Hospital, Chicago, 14, 17, 21 Washington University Medical School, Wood, Francis Carter, 55, 207, 251 403 Woolsey, George, 53n Wathen, John R., 479 World Affairs Webster, J. Clarence, 5 1900, 24-25 Weicker, Elizabeth Miller, 438 1903-10, 32, 129 Weiskotten, Herman G., 387 1914, 155, 158 Wells, Brooks, 28, 53n 1915-16, 168, 177, 191 Werder, X. 0., 479 1917-18, 195-196, 211-214, 224 Wesley Memorial Hospital, Chicago, 18, 1920-29, 268, 284-285 21 1930-39, 302-304 West, Olin, 312-313 1940-49, 349, 369-370 Western Surgical Association, 86, 108, 1950-59, 405, 442-443 337, 343 World Congress of Physicians and Sur- Whipple, Allen 0., 286, 336, 342 geons, 224 Whitacre, Rolland J., 387 World War I, 155, 158-159, 168-169, Whitman, Howard, 433 177, 191-193, 195-196, 211-214 Wilbur, Ray Lyman, 304 World War II, 366, 369-370 Wilinsky, Charles F., 387 World's Fair, Chicago, 1893, 20 Will County, Illinois, 415 Wright, Arthur, 55, 251 Williams, J. A., 44 Wright, Louis T., 332 Williams, Daniel H., 124-126, 332 Yates, John L., 256, 492 Williams, Greer, 415 Yocum, James R., 479 Wills, Brooks, 28 Zapffe, Fred C., 286 Wilson, John P., 225 Zentralblatt filr Chirurgie, 59 Wilson, L. B., 251 Zentrallblatt fiir Gynecologic, 50

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